© 2011 McGraw-Hill Higher Education. All rights reserved B ELLWORK Get Unit 3: Legal Concerns &...

© 2011 McGraw-Hill Higher Education. All rights reserved

BELLWORKGet Unit 3: Legal Concerns &

Insurance Issues Book Chapter Outline


Categorize the essential insurance requirements for the protection of the patient

The state of being legally responsible for the harm one causes another person

Legal wrongs committed against a person Provides limited protection against legal

liability to any individual who voluntarily chooses to provide first aid

TortsNonfeasanceMalfeasanceMisfeasance


HMO, PPO, POS, EPO, PHO, TPA, Medicare, Medicade, Workers Compensation, Indemnity Plan, Capitation

A provision in an insurance policy requiring the policyholder to pay a specific percentage of each medical claim

The amount owed by the insured on a yearly basis before the insurance company will begin to pay for services rendered

A periodic payment made to an insurance company by an individual policy

Description of Billing Codes used by Athletic Trainers


OBJECTIVETopic: Legal Concerns & Insurance Issues

Do: Describe parts of negligence & Create a scenario on negligence

L.O.T: Creating


CHAPTER 3: LEGAL CONCERNS AND INSURANCE ISSUES


LEGAL CONCERNS FOR THE ATHLETIC TRAINERLawsuits have become the rule rather than the exception

Athletic trainers are held accountable for their patient careWhat they do and don’t do


NEW VOCAB WORDReceive a new unit vocabulary sheet


LIABILITYDefinition

The state of being legally responsible for the harm one causes another person


LIABILITYUses/ Elaboration:

Athletic Trainers are liable for their actions- can be sued


LIABILITY


NEGLIGENCEDefinition

The failure to use ordinary or reasonable care


NEGLIGENCEUses/ Elaboration:

Care that persons would normally do to avoid injury to themselves or others

Commonsense approach to the situation

Operate within limits of educational background/ license


NEGLIGENCE


DUTY OF CAREDefinition

Part of the official job description


DUTY OF CAREUses/ Elaboration:

What the person is suppose to do


DUTY OF CARE


TO PROVE NEGLIGENCEDuty to CareBreach of duty (Conduct fell short)

Damages (Injury/ $)


THINK, PAIR, SHAREThink of a person/ entity in sports

(coach, athletic director, ATC, team doctor, school) and create a scenario on how they could get sued for negligence

Need to show:Duty to CareBreach of DutyDamages


BELLWORKWhat are the 3 things one must prove in order to successfully sue for negligence?Duty to CareBeach of DutyDamages


OBJECTIVETopic: Torts (Legal Wrongs) & Legal Protection

Do: Examine & Analyze if there is a Tort

L.O.T.: Analyzing


NEW VOCAB WORD Get out your vocab sheet


TORTSDefinition:

Legal wrongs committed against a person or property of another


TORTSUses/ Elaborations:

Doing something wrong intentionally or by negligence

Torts serve as a deterrent as stating what is acceptable


TORTS


NONFEASANCEDefinition:

When an individual fails to perform a legal duty


NONFEASANCEUses/ Elaboration:

Also known act of omissionThey do not do something they are

suppose to do


NONFEASANCE


MALFEASANCEDefinition:

An individual commits an act that is not legally his to perform


MALFEASANCEUses/ Elaboration:

Act of commissionDoing something outside of

their duty


MALFEASANCE


MISFEASANCEDefinition:

An individual improperly does something he or she has the legal right to do


MISFEASANCEUses/ Elaboration

Does something wrong they have the legal right to do and there are damages


MISFEASANCE


PROVING NEGLIGENCENegligence suit to be successful

Prove the athletic trainer had a duty to exercise reasonable care

The athletic trainer breached that duty

Connection between the failure to use reasonable care and the injury


OTHER LEGAL ASPECTS Individual with higher level of

training will possess higher level of competenceDoctor vs. Athletic Trainer vs.

Coach

Once an individual assumes duty of care for athlete that person has an obligation to provide appropriate care


LEGAL PROTECTION* NEW VOCAB

Sovereign ImmunityGood Samaritan Law




SOVEREIGN IMMUNITYDefinition:

Neither the government nor any individual who is employed by the government can be held liable for negligence


SOVEREIGN IMMUNITYUses/ Elaboration:

Employed by a public school or state funded college/ university

Varies from state to state


SOVEREIGN IMMUNITY


GOOD SAMARITAN LAWDefinition:

Provides limited protection against legal liability to any person who voluntarily chooses to provide first aid


GOOD SAMARITAN LAWUses/ Elaboration:

Acts within their education and gives reasonable care


GOOD SAMARITAN LAW


SCENARIO- BASEBALL LAWSUITReceive Baseball Lawsuit Scenario

Answer Yes, No & Why


BELLWORKDefine in your own words:

NonfeasanceMalfeasanceMisfeasance


OBJECTIVETopic: Legal Protection & Case Studies

Do: Evaluate, Assess & Discuss Various Case Studies

L.O.T.: Evaluating


STATUTES OF LIMITATION Length of time an individual can sue

for negligence

Varies by state (usually 1-3 years)

Time the negligent act to the lawsuit or from the time injury is discovered following negligent act

Minors have generally have an extension




ASSUMPTION OF RISKDefinition:

The individual, through express or implied agreement, assumes that some risk or danger will be involved in the particular undertaking.


ASSUMPTION OF RISKUses/ Elaboration:

A person takes his/ her own chances


ASSUMPTION OF RISK


PRODUCT LIABILITY Liability of any or all parties involved in

manufactured product Includes manufacturer of components,

assemblers, wholesaler, and retail store owner

Athletic trainers, coaches, etc. should not alter equipmentInvalidates the manufacturers warrantyLiability solely on the athletic trainer,

coach, etc.


Equipment warning labelsInforms of possible dangers with

product useNational Operating Committee on

Standards for Athletic Equipment (NOCSAE)Minimum standards for equipment to ensure safety


CASE STUDY- GROUP WORK

Students divided into small groups

Each group will be given a law case study

Groups will answer the worksheetEach group will give a short

presentation on what the case was and answers to the worksheet


BELLWORKHow much do you think an ACL surgery cost?$35,000

Cost of ER Visit for broken arm (no surgery)?$2,500

Cost of ER visit for scalp stitches?$1,869


OBJECTIVETopic: Insurance Considerations

Do: Identify General Health Care & Insurance

L.O.T.: Remembering


INSURANCE CONSIDERATIONS Managed Care:

Health care cost is monitored by insurance carriers, often needing preapproval

Medical Insurance:Contract between insurance

company and policyholderInsurance company reimburses part

of the medical bill once deductible is meant


GENERAL HEALTH INSURANCE Every person should have Covers illness, hospitalization and

emergency care For schools and institutions:

Primary Insurance- Covers all medical expenses

Secondary Insurance- Pays remaining bills once personal insurance company pays

Family Health Insurance:Personal insurance


ACCIDENT INSURANCELow cost plan to cover accident

on school grounds or in workplaceCover costs associated with

hospital care, surgery, and catastrophic injuries not covered by general insurance

Does not require faultAmount of pay is limited


PROFESSIONAL LIABILITY INSURANCE

Covers claims of negligence on the part of the individual

Covers negligence on a civil case not criminal


CATASTROPHIC INSURANCECatastrophic injuries in athletics are relatively rare, but are staggering

Organizations (NCAA, NAIA, NFSHSA) provide additional coverage to deal with lifetime extensive care


INSURANCE VIDEOHandout video questions

Watch and answer questions

Will go over after video


INSURANCE VIDEO

http://www.khanacademy.org/science/healthcare-and-medicine/v/healthcare-system-overview


INSURANCE VIDEO ANSWERSProvidersInsurersEmployers & PatientsHMOPPO


BELLWORKIn 12 words or less why do you think an athlete should have general insurance?


OBJECTIVETopic: Third Party Reimbursement & Billing

Do: Classify and Evaluate Different Insurances

L.O.T.: Evaluating


THIRD- PARTY REIMBURSEMENTPrimary mechanism of payment

for medical services in the U.S.Insurance company reimburses

health care providers for services rendered

Number of different options but most are pre-arranged systems

Preventative care


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)

Pays 100% of cost if go to HMO facility


PREFERRED PROVIDERS ORGANIZATION (PPO)

Limits to a degree where treatment is obtained

May include additional coverage easier (physical therapy)

PPO pay on a fee-for-service basis


POINT OF SERVICECombination of HMO and PPOBased on HMO model but allows for care outside of the plan

Flexibility is allowed for certain conditions and circumstances


OTHERExclusive Provider Organization

Combo of HMO and PPO but very restrictive

Physician Hospital Organization (PHO)Contracts with hospital chain

Third- Party Administrators (TPA)Pay claims for self-insured group

plans, administration service


MEDICARE & MEDICAIDMedicare:

Federal Health Insurance for the aged & disabled

Medicaid:People with low incomes or limited resources

Combination of federal and state


INSURANCE BILLING & FILING A CLAIM

Must file claims immediately and correctly

Filling a claimMust have a 5 digit diagnostic

code (the condition or the injury)

Current Procedure Terminology (CPT code)- specific medical procedures


DESCRIPTION OF BILLING CODES USED BY ATHLETIC TRAINERS

CPT Codes (Current Procedure Terminology Codes)97005/97006 Athletic trainer evaluation and

reevaluation (per visit)97750 Physical performance test (each 15

minutes) treatment charges97116 Gait training (each 15 minutes)97110 Therapeutic exercise (each 15

minutes)97112 Neuromuscular reeducation (each 15

minutes)97530 Therapeutic activities (each 15

minutes)97113 Aquatic therapeutic exercise (each 15

minutes)97124 Massage (each 15 minutes)97530 Body mechanics training (each 15

minutes)97140 Manual therapy (each 15 minutes)


ASSIGNMENT: INSURANCE SCENARIO

Get Scenario HandoutAnswer questions (Yes, No & Why)

Discuss


PLANGet Unit 3 WorksheetReview for Unit 1, 2 & 3 Test next class period

Unit 1-3 Test day after

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