Chapter 3: Legal Concerns and Related Issues

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Chapter 3 Legal Concerns and Related Issues
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Liability

• State of being legally responsible for the harm
  one causes to another person.

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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

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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)

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• 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)

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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)

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DUTY
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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

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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 athletes
  negligence suit

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• 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

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How do you reduce the risk of litigation as a
coach, athletic trainer/allied health
professional?
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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

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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

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• 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 physicians orders, particularly when
  dealing with participation of athlete
• Purchase liability insurance
• Know scope of practice
• Use common sense

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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

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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)

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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

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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

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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)

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• 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

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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

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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
• ATCs must have working knowledge of HMO limits
  and restrictions

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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

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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

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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

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Capitation

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

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Third-Party Reimbursement for Athletic Trainers

• Rare for ATCs unless they are licensed PTs
• Concern for ATCs working in for-profit private
  clinics
• State licensing and credentialing will aid in
  this process but will remain concern for clinical
  ATCs
• Reimbursement Advisory Group (NATA) responsible
  for assessing managed care and involvement of
  ATCs

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• 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

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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

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• 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