1. © 2011 McGraw-Hill Higher Education. All rights reserved Chapter 3: Legal Concerns and Insurance Issues

2. © 2011 McGraw-Hill Higher Education. All rights reserved Legal Concerns for the Athletic Trainer Lawsuits have become the rule rather than the exception Athletic trainers are held accountable for their patient care, what they do and don’t do

3. © 2011 McGraw-Hill Higher Education. All rights reserved Liability: State of being legally responsible for the harm one causes to another person. An athletic trainer is liable.

4. © 2011 McGraw-Hill Higher Education. All rights reserved Standard of Reasonable Care Negligence – failure to use ordinary or reasonable care Care that persons would normally do to avoid injury to themselves or others Standards of reasonable care –Bring commonsense approach to the situation – Must operate within the appropriate limitations of ones educational background

5. © 2011 McGraw-Hill Higher Education. All rights reserved To Prove Negligence Duty to Care: part of official job description Breach of duty: conduct fell short Damages

6. © 2011 McGraw-Hill Higher Education. All rights reserved 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

7. © 2011 McGraw-Hill Higher Education. All rights reserved Proving Negligence 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

8. © 2011 McGraw-Hill Higher Education. All rights reserved 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

9. © 2011 McGraw-Hill Higher Education. All rights reserved Legal Protection 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

10. © 2011 McGraw-Hill Higher Education. All rights reserved 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

11. © 2011 McGraw-Hill Higher Education. All rights reserved 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

12. © 2011 McGraw-Hill Higher Education. All rights reserved Reducing the Risk of Litigation

13. © 2011 McGraw-Hill Higher Education. All rights reserved 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. © 2011 McGraw-Hill Higher Education. All rights reserved 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. © 2011 McGraw-Hill Higher Education. All rights reserved Follow physician’s orders, particularly when dealing with participation of athlete Purchase liability insurance Know scope of practice Use common sense

16. © 2011 McGraw-Hill Higher Education. All rights reserved 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. © 2011 McGraw-Hill Higher Education. All rights reserved 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 Athletic trainers should not alter equipment –Doing so invalidates the manufacturers warranty –Results in placing liability solely on the athletic trainer

18. © 2011 McGraw-Hill Higher Education. All rights reserved ASSIGNMENT: Lawsuit Scenario Read the handout on the scenario Get into small groups Answer outline Discuss

19. © 2011 McGraw-Hill Higher Education. All rights reserved Insurance Considerations Medical insurance is a contract between the company and policyholder Company agrees to pay portion of medical bills following payment of a deductible

20. © 2011 McGraw-Hill Higher Education. All rights reserved 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. © 2011 McGraw-Hill Higher Education. All rights reserved 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. © 2011 McGraw-Hill Higher Education. All rights reserved Professional Liability Insurance 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

23. © 2011 McGraw-Hill Higher Education. All rights reserved 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. © 2011 McGraw-Hill Higher Education. All rights reserved 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

25. © 2011 McGraw-Hill Higher Education. All rights reserved Health Maintenance Organization (HMO) Provide preventive measures and dictate where individual can receive care Permission must be gained to see someone outside of the plan (except in emergencies)

26. © 2011 McGraw-Hill Higher Education. All rights reserved Preferred Providers Organization (PPO) 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

27. © 2011 McGraw-Hill Higher Education. All rights reserved 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

28. © 2011 McGraw-Hill Higher Education. All rights reserved 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

29. © 2011 McGraw-Hill Higher Education. All rights reserved 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

30. © 2011 McGraw-Hill Higher Education. All rights reserved 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

31. © 2011 McGraw-Hill Higher Education. All rights reserved 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

32. © 2011 McGraw-Hill Higher Education. All rights reserved 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

33. © 2011 McGraw-Hill Higher Education. All rights reserved 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

34. © 2011 McGraw-Hill Higher Education. All rights reserved 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

35. © 2011 McGraw-Hill Higher Education. All rights reserved Capitation Form of reimbursement where members make standard payment monthly regardless of services rendered Managed care plans utilize this practice

36. © 2011 McGraw-Hill Higher Education. All rights reserved 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

37. © 2011 McGraw-Hill Higher Education. All rights reserved 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

38. © 2011 McGraw-Hill Higher Education. All rights reserved ASSIGNMENT: Insurance Scenario Get Scenario Handout Read Scenario Get in small groups Answer questions Discuss