1. Chapter 3: Legal Concerns and Related Issues

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

3. 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

4. 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)

5. 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)

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.
Athletic trainer has a duty to provide coverage to athletes (obligation)

7. DUTY

8. 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

9. 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 athlete’s negligence suit

10. 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

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

12. 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

13. 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

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

15. 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

16. 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)

17. 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

18. 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

19. 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)

20. 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

21. 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

22. 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
ATC’s must have working knowledge of HMO limits and restrictions

23. 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

24. 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

25. 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

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

27. Third-Party Reimbursement for Athletic Trainers
Rare for ATC’s unless they are licensed PT’s
Concern for ATC’s working in for-profit private clinics
State licensing and credentialing will aid in this process but will remain concern for clinical ATC’s
Reimbursement Advisory Group (NATA) responsible for assessing managed care and involvement of ATC’s

28. 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

29. 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

30. 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