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

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Presentation on theme: "© 2011 McGraw-Hill Higher Education. All rights reserved B ELLWORK Get Unit 3: Legal Concerns & Insurance Issues Book Chapter Outline."— Presentation transcript:

1 © 2011 McGraw-Hill Higher Education. All rights reserved B ELLWORK Get Unit 3: Legal Concerns & Insurance Issues Book Chapter Outline

2 © 2011 McGraw-Hill Higher Education. All rights reserved 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 Torts Nonfeasance Malfeasance Misfeasance

3 © 2011 McGraw-Hill Higher Education. All rights reserved 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

4 © 2011 McGraw-Hill Higher Education. All rights reserved O BJECTIVE Topic: Legal Concerns & Insurance Issues Do: Describe parts of negligence & Create a scenario on negligence L.O.T: Creating

5 © 2011 McGraw-Hill Higher Education. All rights reserved C HAPTER 3: L EGAL C ONCERNS AND I NSURANCE I SSUES

6 © 2011 McGraw-Hill Higher Education. All rights reserved L EGAL C ONCERNS FOR THE A THLETIC T RAINER Lawsuits have become the rule rather than the exception Athletic trainers are held accountable for their patient care What they do and dont do

7 © 2011 McGraw-Hill Higher Education. All rights reserved N EW V OCAB W ORD Receive a new unit vocabulary sheet

8 © 2011 McGraw-Hill Higher Education. All rights reserved L IABILITY Definition The state of being legally responsible for the harm one causes another person

9 © 2011 McGraw-Hill Higher Education. All rights reserved L IABILITY Uses/ Elaboration: Athletic Trainers are liable for their actions- can be sued

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

11 © 2011 McGraw-Hill Higher Education. All rights reserved N EGLIGENCE Definition The failure to use ordinary or reasonable care

12 © 2011 McGraw-Hill Higher Education. All rights reserved N EGLIGENCE Uses/ 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

13 © 2011 McGraw-Hill Higher Education. All rights reserved N EGLIGENCE

14 © 2011 McGraw-Hill Higher Education. All rights reserved D UTY OF C ARE Definition Part of the official job description

15 © 2011 McGraw-Hill Higher Education. All rights reserved D UTY OF C ARE Uses/ Elaboration: What the person is suppose to do

16 © 2011 McGraw-Hill Higher Education. All rights reserved D UTY OF C ARE

17 © 2011 McGraw-Hill Higher Education. All rights reserved T O P ROVE N EGLIGENCE Duty to Care Breach of duty (Conduct fell short) Damages (Injury/ $)

18 © 2011 McGraw-Hill Higher Education. All rights reserved T HINK, P AIR, S HARE Think 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 Care Breach of Duty Damages

19 © 2011 McGraw-Hill Higher Education. All rights reserved B ELLWORK What are the 3 things one must prove in order to successfully sue for negligence? Duty to Care Beach of Duty Damages

20 © 2011 McGraw-Hill Higher Education. All rights reserved O BJECTIVE Topic: Torts (Legal Wrongs) & Legal Protection Do: Examine & Analyze if there is a Tort L.O.T.: Analyzing

21 © 2011 McGraw-Hill Higher Education. All rights reserved N EW V OCAB W ORD Get out your vocab sheet

22 © 2011 McGraw-Hill Higher Education. All rights reserved T ORTS Definition: Legal wrongs committed against a person or property of another

23 © 2011 McGraw-Hill Higher Education. All rights reserved T ORTS Uses/ Elaborations: Doing something wrong intentionally or by negligence Torts serve as a deterrent as stating what is acceptable

24 © 2011 McGraw-Hill Higher Education. All rights reserved T ORTS

25 © 2011 McGraw-Hill Higher Education. All rights reserved N ONFEASANCE Definition: When an individual fails to perform a legal duty

26 © 2011 McGraw-Hill Higher Education. All rights reserved N ONFEASANCE Uses/ Elaboration: Also known act of omission They do not do something they are suppose to do

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

28 © 2011 McGraw-Hill Higher Education. All rights reserved M ALFEASANCE Definition: An individual commits an act that is not legally his to perform

29 © 2011 McGraw-Hill Higher Education. All rights reserved M ALFEASANCE Uses/ Elaboration: Act of commission Doing something outside of their duty

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

31 © 2011 McGraw-Hill Higher Education. All rights reserved M ISFEASANCE Definition: An individual improperly does something he or she has the legal right to do

32 © 2011 McGraw-Hill Higher Education. All rights reserved M ISFEASANCE Uses/ Elaboration Does something wrong they have the legal right to do and there are damages

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

34 © 2011 McGraw-Hill Higher Education. All rights reserved P ROVING N EGLIGENCE Negligence 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

35 © 2011 McGraw-Hill Higher Education. All rights reserved O THER L EGAL A SPECTS Individual with higher level of training will possess higher level of competence Doctor vs. Athletic Trainer vs. Coach Once an individual assumes duty of care for athlete that person has an obligation to provide appropriate care

36 © 2011 McGraw-Hill Higher Education. All rights reserved L EGAL P ROTECTION * N EW V OCAB Sovereign Immunity Good Samaritan Law

37 © 2011 McGraw-Hill Higher Education. All rights reserved N EW V OCAB W ORD Get out your vocab sheet

38 © 2011 McGraw-Hill Higher Education. All rights reserved S OVEREIGN I MMUNITY Definition: Neither the government nor any individual who is employed by the government can be held liable for negligence

39 © 2011 McGraw-Hill Higher Education. All rights reserved S OVEREIGN I MMUNITY Uses/ Elaboration: Employed by a public school or state funded college/ university Varies from state to state

40 © 2011 McGraw-Hill Higher Education. All rights reserved S OVEREIGN I MMUNITY

41 © 2011 McGraw-Hill Higher Education. All rights reserved G OOD S AMARITAN L AW Definition: Provides limited protection against legal liability to any person who voluntarily chooses to provide first aid

42 © 2011 McGraw-Hill Higher Education. All rights reserved G OOD S AMARITAN L AW Uses/ Elaboration: Acts within their education and gives reasonable care

43 © 2011 McGraw-Hill Higher Education. All rights reserved G OOD S AMARITAN L AW

44 © 2011 McGraw-Hill Higher Education. All rights reserved S CENARIO - B ASEBALL L AWSUIT Receive Baseball Lawsuit Scenario Answer Yes, No & Why

45 © 2011 McGraw-Hill Higher Education. All rights reserved B ELLWORK Define in your own words: Nonfeasance Malfeasance Misfeasance

46 © 2011 McGraw-Hill Higher Education. All rights reserved O BJECTIVE Topic: Legal Protection & Case Studies Do: Evaluate, Assess & Discuss Various Case Studies L.O.T.: Evaluating

47 © 2011 McGraw-Hill Higher Education. All rights reserved S TATUTES OF L IMITATION 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

48 © 2011 McGraw-Hill Higher Education. All rights reserved N EW V OCAB W ORD Get out your vocab sheet

49 © 2011 McGraw-Hill Higher Education. All rights reserved A SSUMPTION OF R ISK Definition: The individual, through express or implied agreement, assumes that some risk or danger will be involved in the particular undertaking.

50 © 2011 McGraw-Hill Higher Education. All rights reserved A SSUMPTION OF R ISK Uses/ Elaboration: A person takes his/ her own chances

51 © 2011 McGraw-Hill Higher Education. All rights reserved A SSUMPTION OF R ISK

52 © 2011 McGraw-Hill Higher Education. All rights reserved P RODUCT L IABILITY 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 equipment Invalidates the manufacturers warranty Liability solely on the athletic trainer, coach, etc.

53 © 2011 McGraw-Hill Higher Education. All rights reserved Equipment warning labels Informs of possible dangers with product use National Operating Committee on Standards for Athletic Equipment (NOCSAE) Minimum standards for equipment to ensure safety

54 © 2011 McGraw-Hill Higher Education. All rights reserved C ASE S TUDY - G ROUP W ORK Students divided into small groups Each group will be given a law case study Groups will answer the worksheet Each group will give a short presentation on what the case was and answers to the worksheet

55 © 2011 McGraw-Hill Higher Education. All rights reserved B ELLWORK How 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

56 © 2011 McGraw-Hill Higher Education. All rights reserved O BJECTIVE Topic: Insurance Considerations Do: Identify General Health Care & Insurance L.O.T.: Remembering

57 © 2011 McGraw-Hill Higher Education. All rights reserved I NSURANCE C ONSIDERATIONS Managed Care: Health care cost is monitored by insurance carriers, often needing preapproval Medical Insurance: Contract between insurance company and policyholder Insurance company reimburses part of the medical bill once deductible is meant

58 © 2011 McGraw-Hill Higher Education. All rights reserved G ENERAL H EALTH I NSURANCE 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

59 © 2011 McGraw-Hill Higher Education. All rights reserved A CCIDENT I NSURANCE Low cost plan to cover accident on school grounds or in workplace Cover costs associated with hospital care, surgery, and catastrophic injuries not covered by general insurance Does not require fault Amount of pay is limited

60 © 2011 McGraw-Hill Higher Education. All rights reserved P ROFESSIONAL L IABILITY I NSURANCE Covers claims of negligence on the part of the individual Covers negligence on a civil case not criminal

61 © 2011 McGraw-Hill Higher Education. All rights reserved C ATASTROPHIC I NSURANCE Catastrophic injuries in athletics are relatively rare, but are staggering Organizations (NCAA, NAIA, NFSHSA) provide additional coverage to deal with lifetime extensive care

62 © 2011 McGraw-Hill Higher Education. All rights reserved I NSURANCE V IDEO Handout video questions Watch and answer questions Will go over after video

63 © 2011 McGraw-Hill Higher Education. All rights reserved I NSURANCE V IDEO http://www.khanacademy.org/science/healthcare- and-medicine/v/healthcare-system-overview http://www.khanacademy.org/science/healthcare- and-medicine/v/healthcare-system-overview

64 © 2011 McGraw-Hill Higher Education. All rights reserved I NSURANCE V IDEO A NSWERS Providers Insurers Employers & Patients HMO PPO

65 © 2011 McGraw-Hill Higher Education. All rights reserved B ELLWORK In 12 words or less why do you think an athlete should have general insurance?

66 © 2011 McGraw-Hill Higher Education. All rights reserved O BJECTIVE Topic: Third Party Reimbursement & Billing Do: Classify and Evaluate Different Insurances L.O.T.: Evaluating

67 © 2011 McGraw-Hill Higher Education. All rights reserved T HIRD - P ARTY R EIMBURSEMENT Primary 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

68 © 2011 McGraw-Hill Higher Education. All rights reserved H EALTH M AINTENANCE O RGANIZATION (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

69 © 2011 McGraw-Hill Higher Education. All rights reserved P REFERRED P ROVIDERS O RGANIZATION (PPO) Limits to a degree where treatment is obtained May include additional coverage easier (physical therapy) PPO pay on a fee-for-service basis

70 © 2011 McGraw-Hill Higher Education. All rights reserved P OINT OF S ERVICE 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

71 © 2011 McGraw-Hill Higher Education. All rights reserved O THER Exclusive 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

72 © 2011 McGraw-Hill Higher Education. All rights reserved M EDICARE & M EDICAID Medicare: Federal Health Insurance for the aged & disabled Medicaid: People with low incomes or limited resources Combination of federal and state

73 © 2011 McGraw-Hill Higher Education. All rights reserved I NSURANCE B ILLING & F ILING A CLAIM Must file claims immediately and correctly Filling a claim Must have a 5 digit diagnostic code (the condition or the injury) Current Procedure Terminology (CPT code)- specific medical procedures

74 © 2011 McGraw-Hill Higher Education. All rights reserved D ESCRIPTION OF B ILLING C ODES U SED BY A THLETIC T RAINERS CPT Codes (Current Procedure Terminology Codes) 97005/97006Athletic trainer evaluation and reevaluation (per visit) 97750Physical performance test (each 15 minutes) treatment charges 97116Gait training (each 15 minutes) 97110Therapeutic exercise (each 15 minutes) 97112Neuromuscular reeducation (each 15 minutes) 97530Therapeutic activities (each 15 minutes) 97113Aquatic therapeutic exercise (each 15 minutes) 97124Massage (each 15 minutes) 97530Body mechanics training (each 15 minutes) 97140Manual therapy (each 15 minutes)

75 © 2011 McGraw-Hill Higher Education. All rights reserved ASSIGNMENT: I NSURANCE S CENARIO Get Scenario Handout Answer questions (Yes, No & Why) Discuss

76 © 2011 McGraw-Hill Higher Education. All rights reserved P LAN Get Unit 3 Worksheet Review for Unit 1, 2 & 3 Test next class period Unit 1-3 Test day after


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