Transcript Legal Concerns and Related Issues

Chapter 3: Legal Concerns
and Related Issues
Liability:
State of being legally
responsible for the harm
one causes to another
person.
Standard of Reasonable Care
•Negligence: the failure to use ordinary
or reasonable care.
•Standards of reasonable care
–assumes that a person is of ordinary and
reasonable prudence
–bring commonsense approach to the
situation
–must operate within the appropriate
limitations of ones educational background
Torts
•Legal wrongs committed against a
person (liability results)
•May emanate from
–act of omission (fail to perform legal
duty, i.e. fail to refer)
–act of commission (performs action that
is not his/hers to legally perform,
i.e. perform advanced treatment
leading to complications)
Act of omission: individual fails to
perform a legal duty (fail to refer)
Act of commission: individual
performs an act that is legally not
his/hers to perform (advanced
treatment leading to complications)
Proving Negligence
•Care giver does something a reasonably
prudent individual would not.
•Care giver fails to do something a
reasonably prudent individual would not.
•Athletic trainer has a duty to provide
coverage to athletes (obligation)
DUTY
Statutes of Limitation
•Specific length of time an individual can
sue for injury resulting from negligence.
•Varies by state but generally ranges from
one to three years
•Clock begins at the time the negligent act
results in suit or from the time injury is
discovered following negligent act
•Minors have generally have an extension
Assumption of Risk
•Athlete is made aware of inherent risks
involved in sport and voluntarily decides
to continue participating
•Expressed in written waiver or implied
from conduct of athlete once participation
begins
•Can be used as defense against an
athlete’s negligence suit
• Does not excuse overseers from exhibiting
reasonable care and prudence in regards to
conduct of activities or foreseeing potential
hazards
• Many and varied interpretations
(particularly with minors)
• Often a waiver will stand in court except in
incidents of fraud, misrepresentation or
duress
How do you reduce
the risk of litigation
as a coach, athletic
trainer/allied health
professional?
Coach
• Warn athletes of potential dangers
involved in sport
• Supervise regularly and attentively
• Prepare and condition athletes
• Instruct athletes on skills of their
respective sports
• Ensure proper and safe equipment and
facilities
Athletic Trainer
• Work to establish good working
relationships with athletes, parents and
coworkers
• Establish policies regarding athletic
training facility and coverage
• Develop emergency action plan
• Know the medical history of athletes
• Maintain adequate records
• Detailed job description
• Obtain written consent relative to
providing health care
• Maintain confidentiality
• Exercise caution with regards to
medication distribution and modality use
• Ensure safe equipment and facilities
• Follow physician’s orders, particularly
when dealing with participation of athlete
• Purchase liability insurance
• Know scope of practice
• Use common sense
Insurance
• Major changes in insurance have
occurred in light of managed care
• Major increases in the number of
lawsuits and cost of insurance
• Medical insurance is a contract between
the company and policyholder
• Company agrees to pay portion of
medical bills following payment of a
deductible
General Health Insurance
• Policy that covers illnesses, hospitalization
and emergency care
• Sometimes offered through academic
institutions for students (athletics)
• Secondary insurance provided through
institutions to cover costs above primary
insurance coverage
• Schools and universities must ensure that
athletes have primary insurance coverage (in
place or arranged for)
Accident Insurance
• Low cost plan to cover accident on school
grounds
• Protects against financial loss from
medical and hospital bills
• Provides for additional protection for
institution above regular policy
• Will cover costs associated with hospital
care, surgery, and catastrophic injuries
Professional Liability
Insurance
• Protect against damages that may arise
from injuries occurring on school property
• Covers against claims of negligence on part
of individuals
• Because of rise in lawsuits, professionals
must be fully protected, particularly in
regards to negligence
Catastrophic Insurance
• Catastrophic injuries in athletics are
relatively rare, but are staggering to all
involved
• Organizations (NCAA, NAIA, NFSHSA)
provide additional coverage to deal with
lifetime extensive care
• Errors and omissions liability insurance
has evolved to protect individuals against
suits claiming malpractice, negligence,
errors and omissions (have personal
liability insurance)
• Ensuring that all athletes and
faculty/staff coverage is in place is
critically important
• Filing of claims, at times, is the
responsibility of the athletic trainer
• Can be very time consuming taking the
ATC away from other responsibilities
• Additional staff may be necessary to deal
with added responsibilities
Third-Party Reimbursement
• Primary mechanism of payment for
medical services in the U.S.
• Policyholder insurance company
reimburses health care providers for
services rendered
• Number of different options
– Pre-arranged systems
– Payment for preventive care
– Other systems developed to contain costs
Health Maintenance
Organization
• Provide preventive measures and dictate
where individual can receive care
• Permission must be gained to see
someone outside of the plan (except in
emergencies)
• HMO will pay 100% of costs if care
rendered within the HMO plan providers
• ATC’s must have working knowledge of
HMO limits and restrictions
Preferred Providers
Organization
• Provide discount health care and also
limit where treatment can be obtained
• Must be aware of what facilities are
approved for the program in order have
cost completely covered
• May include additional types of coverage
(physical therapy)
• PPO pay on a fee-for-service basis
Point of Service
• Combination of HMO and PPO
• Based on HMO model but allows for care
outside of the plan
• Flexibility is allowed for certain
conditions and circumstances
Indemnity Plan
• Most traditional form of billing for health
care
• Fee-for-service plan that allows insured
party to seek care without restrictions
• Provider charges patient or third-party
payer
• Charges are set on fee schedule
Capitation
• Form of reimbursement where members
make standard payment monthly
regardless of services rendered
• Managed care plans utilize this practice
Third-Party Reimbursement
for Athletic Trainers
• Rare for ATC’s unless they are licensed
PT’s
• Concern for ATC’s working in for-profit
private clinics
• State licensing and credentialing will aid
in this process but will remain concern
for clinical ATC’s
• Reimbursement Advisory Group (NATA)
responsible for assessing managed care
and involvement of ATC’s
• Athletic Training Outcome Assessment
project (NATA) developed to present
results of 3 year study
• Study focussed on functional outcomes,
perceptions of care, physical, social,
mental well-being, time lost due to injury
and satisfaction of care and treatment
• Third-party payers require outcomes
research when evaluating a contract
Insurance Billing
• Must file claims immediately and correctly
• To facilitate, collect insurance information at
the start of the academic year
• Letters should be sent home to fully explain
the coverage available and necessary
procedures
• Standard forms are the norm, but accurate
and thorough completion is critical
• ATC in clinical setting must be aware of
third-party billing procedures
• May need to request approval from
insurance companies for treatments to be
rendered
• Billing must be in accordance with
Current Procedural Terminology set by
AMA
• APTA has also submitted billing codes
appropriate for the industry