1. Chapter 3: Legal Concerns and Insurance Issues

2. Legal Concerns for the Athletic Trainer
Critical to be mindful of the litigious nature of our society as it relates to healthcare
Athletic trainers are held accountable for their patient care
Potential exists that techniques and procedures used by athletic trainers may result in legal action due to issues of liability and negligence

3. Liability:
State of being legally responsible for the harm one causes to another person.

4. Standard of Reasonable Care
Negligence
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

5. Torts Legal wrongs committed against a person (liability results)
May emanate from
Nonfeasance
Fail to perform legal duty (i.e. fail to refer)
Malfeasance
Performs action that is not his/hers to legally perform (i.e. perform advanced treatment leading to complications)
Misfeasance
Performs an action incorrectly that the he/she has the legal right to do

6. Proving Negligence
Care giver does something a reasonably prudent individual would not.
Care giver fails to do something a reasonably prudent individual would not.
For a negligence suit to be successful
Must prove the athletic trainer had a duty to exercise reasonable care
The athletic trainer breached that duty
Establish a connection between the failure to use reasonable care and the injury suffered by the individual

7. Individual possessing higher level of training will possess higher level of competence
Once coach or athletic trainer assumes duty of caring for athlete that person has an obligation to provide appropriate care
Obligation to provide services vs. Scope of employment

8. An athletic trainer at an institution has a duty to provide care to individuals at the institution
May be protected through sovereign immunity
Sovereign Immunity
Neither the government nor individuals employed by the government can be held liable for negligence
May vary state to state
Good Samaritan Law
Provides limited protection against legal liability to one that provides care should something go wrong

9. 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

10. Assumption of Risk
Individual 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 individual’s negligence suit

11. 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

12. Reducing the Risk of Litigation

13. Athletic Trainer
Work to establish good working relationships with athletes, parents, patients, and coworkers
Establish policies regarding athletic training facility and coverage
Develop emergency action plan
Become familiar with medical history of individuals under your care
Maintain adequate records

14. 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
Develop an understanding with coaches on how and when injured participants will be cleared for return to play
Allow injured players to return following physician clearance

15. Follow physician’s orders, particularly when dealing with participation of athlete
Purchase liability insurance
Know scope of practice
Use common sense

16. Product Liability
Liability of any or all parties involved in manufactured product for damages caused by product
Includes manufacturer of components, assemblers, wholesaler, and retail store owner
Products with inherent defects are subject to liability suits
May be based on negligence, strict liability or breach of warranty fitness

17. Equipment warning labels
Manufacturer of equipment has duty to design and produce equipment that will not cause injury
Express warranty
Manufacturer’s written guarantee – product safety
Equipment warning labels
Informs individual of possible dangers inherent with product use
National Operating Committee on Standards for Athletic Equipment (NOCSAE)
Minimum standards for equipment to ensure safety

18. Athletic trainers should not alter equipment
Doing so invalidates the manufacturers warranty
Results in placing liability solely on the athletic trainer

19. Insurance Considerations
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

20. 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 individuals have primary insurance coverage (in place or arranged for)

21. Accident Insurance
Low cost plan to cover accident on school grounds or in workplace
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

22. Professional Liability Insurance
Most employees have insurance to protect against damages that may arise from injuries occurring on their property
Liability insurance covers against claims of negligence on part of individuals
Because of rise in lawsuits, professionals must be fully protected, particularly in regards to negligence
All ATs should carry and understand limits of coverage

23. 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

24. Errors and omissions liability insurance has evolved to protect individuals against suits claiming malpractice, negligence, errors and omissions
Individuals within program should have personal liability insurance
Ensuring that all athletes and faculty/staff coverage is in place is critically important

25. Filing of claims, at times, is the responsibility of the athletic trainer
Can be very time consuming taking the AT away from other responsibilities
Additional staff may be necessary to deal with added responsibilities

26. 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

27. 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)

28. HMO will pay 100% of costs if care rendered within the HMO plan providers
ATs must have working knowledge of HMO limits and restrictions

29. 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

30. 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

31. Exclusive Provider Organization
Combination of HMO and PPO plans
Restrictive in number and type of providers ( more like HMO)
Most will not pay anything if you use out of network providers

32. Physician Hospital Organization
Involves a major hospital or hospital chain and its physicians
PHO organization contract directly with employers to provide services and or contracts with managed care organizations

33. Third Party Administrators
Used to administer services
Pay claims for self-insured group plans functioning as a pseudo insurance company
Perform member services
Enrollment and billing
Assist with controlling utilization without financial risk

34. Medicare Federal health insurance program for the aged and disabled
Most people age qualify for benefits
Two parts
A: Hospital portion – premium free at retirement to beneficiaries
B: Physician portion – monthly premium charge

35. Medicaid
Health insurance program for people with low incomes and limited resources
Funded via federal government and individual states
Individual states administer Medicaid
Benefits will vary by state

36. Workers Compensation
Laws and benefits for injured workers are mandated by states
Employer pays premiums
Claims are settled by workers compensation insurance carriers
Insurance carrier goal – return worker to work as soon as possible

37. 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

38. Capitation
Form of reimbursement where members make standard payment monthly regardless of services rendered
Managed care plans utilize this practice

39. Third-Party Reimbursement for Athletic Trainers
ATs have been able to bill third parties
Most insurance companies refuse to reimburse
Recently, increases in reimbursement in a variety of settings has been noted
Third-party payers viewed “licensed health care professional” as reimbursable
In most states this included ATs

40. Reimbursement Advisory Group (NATA) responsible for assessing changes in managed care and helping athletic trainers secure a place as a health care provider
Athletic Training Outcome Assessment project (NATA) developed to present results of 3 year study
Study focused on functional outcomes, perceptions of care, physical, social, mental well-being, time lost due to injury and satisfaction of care and treatment

41. Centers for Medicare & Medicaid Services (CMS) Ruling
Third-party payers require outcomes research when evaluating a contract
Centers for Medicare & Medicaid Services (CMS) Ruling
Ruling states that they would no longer provide reimbursement for services unless provided by a physical, occupational or speech language therapist
Does not allow physicians to bill for services rendered by ATs
Federal government does not recognize ATs as providers of rehab services for Medicare patients at any age

42. May also impact legislation both at the state and federal level
Ruling has had major implications for those ATs working in clinics and hospitals as physician extenders
May also impact legislation both at the state and federal level
The NATA continues to work to reverse this ruling
In 2009, Athletic Trainers Equal Access to Medicare Act (H.R. 1137) was introduced to the US House of Representatives
Allows for Medicare beneficiaries to receive care provided by AT’s
Securing third-party reimbursement for athletic training services must remain a priority

43. 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

44. Filing an Insurance Claim
Standard forms are utilized
Must be complete and detailed
More accuracy and thoroughness = quick return and higher rate of reimbursement
Billing Codes
Diagnostic code
Specifies injury/condition that is being treated
Procedural code

45. ATs 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
Thorough record keeping is critical throughout the process

46. National Provider Identifier (NPI)
Government issued identification number for individual health care providers and organizations
Covered health care providers health plans, and health care clearinghouses must use NPI in all administrative and financial transactions according to HIPPA
As of 2007, all electronic transactions (claims, verifications, inquiries) require use of this 10 digit number