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Transcript of © 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
© 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
TortsNonfeasanceMalfeasanceMisfeasance
© 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
© 2011 McGraw-Hill Higher Education. All rights reserved
OBJECTIVETopic: Legal Concerns & Insurance Issues
Do: Describe parts of negligence & Create a scenario on negligence
L.O.T: Creating
© 2011 McGraw-Hill Higher Education. All rights reserved
CHAPTER 3: LEGAL CONCERNS AND INSURANCE ISSUES
© 2011 McGraw-Hill Higher Education. All rights reserved
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
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NEW VOCAB WORDReceive a new unit vocabulary sheet
© 2011 McGraw-Hill Higher Education. All rights reserved
LIABILITYDefinition
The state of being legally responsible for the harm one causes another person
© 2011 McGraw-Hill Higher Education. All rights reserved
LIABILITYUses/ Elaboration:
Athletic Trainers are liable for their actions- can be sued
© 2011 McGraw-Hill Higher Education. All rights reserved
LIABILITY
© 2011 McGraw-Hill Higher Education. All rights reserved
NEGLIGENCEDefinition
The failure to use ordinary or reasonable care
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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
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NEGLIGENCE
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DUTY OF CAREDefinition
Part of the official job description
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DUTY OF CAREUses/ Elaboration:
What the person is suppose to do
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DUTY OF CARE
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TO PROVE NEGLIGENCEDuty to CareBreach of duty (Conduct fell short)
Damages (Injury/ $)
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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
© 2011 McGraw-Hill Higher Education. All rights reserved
BELLWORKWhat are the 3 things one must prove in order to successfully sue for negligence?Duty to CareBeach of DutyDamages
© 2011 McGraw-Hill Higher Education. All rights reserved
OBJECTIVETopic: Torts (Legal Wrongs) & Legal Protection
Do: Examine & Analyze if there is a Tort
L.O.T.: Analyzing
© 2011 McGraw-Hill Higher Education. All rights reserved
NEW VOCAB WORD Get out your vocab sheet
© 2011 McGraw-Hill Higher Education. All rights reserved
TORTSDefinition:
Legal wrongs committed against a person or property of another
© 2011 McGraw-Hill Higher Education. All rights reserved
TORTSUses/ Elaborations:
Doing something wrong intentionally or by negligence
Torts serve as a deterrent as stating what is acceptable
© 2011 McGraw-Hill Higher Education. All rights reserved
TORTS
© 2011 McGraw-Hill Higher Education. All rights reserved
NONFEASANCEDefinition:
When an individual fails to perform a legal duty
© 2011 McGraw-Hill Higher Education. All rights reserved
NONFEASANCEUses/ Elaboration:
Also known act of omissionThey do not do something they are
suppose to do
© 2011 McGraw-Hill Higher Education. All rights reserved
NONFEASANCE
© 2011 McGraw-Hill Higher Education. All rights reserved
MALFEASANCEDefinition:
An individual commits an act that is not legally his to perform
© 2011 McGraw-Hill Higher Education. All rights reserved
MALFEASANCEUses/ Elaboration:
Act of commissionDoing something outside of
their duty
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MALFEASANCE
© 2011 McGraw-Hill Higher Education. All rights reserved
MISFEASANCEDefinition:
An individual improperly does something he or she has the legal right to do
© 2011 McGraw-Hill Higher Education. All rights reserved
MISFEASANCEUses/ Elaboration
Does something wrong they have the legal right to do and there are damages
© 2011 McGraw-Hill Higher Education. All rights reserved
MISFEASANCE
© 2011 McGraw-Hill Higher Education. All rights reserved
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
© 2011 McGraw-Hill Higher Education. All rights reserved
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
© 2011 McGraw-Hill Higher Education. All rights reserved
LEGAL PROTECTION* NEW VOCAB
Sovereign ImmunityGood Samaritan Law
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NEW VOCAB WORD Get out your vocab sheet
© 2011 McGraw-Hill Higher Education. All rights reserved
SOVEREIGN IMMUNITYDefinition:
Neither the government nor any individual who is employed by the government can be held liable for negligence
© 2011 McGraw-Hill Higher Education. All rights reserved
SOVEREIGN IMMUNITYUses/ Elaboration:
Employed by a public school or state funded college/ university
Varies from state to state
© 2011 McGraw-Hill Higher Education. All rights reserved
SOVEREIGN IMMUNITY
© 2011 McGraw-Hill Higher Education. All rights reserved
GOOD SAMARITAN LAWDefinition:
Provides limited protection against legal liability to any person who voluntarily chooses to provide first aid
© 2011 McGraw-Hill Higher Education. All rights reserved
GOOD SAMARITAN LAWUses/ Elaboration:
Acts within their education and gives reasonable care
© 2011 McGraw-Hill Higher Education. All rights reserved
GOOD SAMARITAN LAW
© 2011 McGraw-Hill Higher Education. All rights reserved
SCENARIO- BASEBALL LAWSUITReceive Baseball Lawsuit Scenario
Answer Yes, No & Why
© 2011 McGraw-Hill Higher Education. All rights reserved
BELLWORKDefine in your own words:
NonfeasanceMalfeasanceMisfeasance
© 2011 McGraw-Hill Higher Education. All rights reserved
OBJECTIVETopic: Legal Protection & Case Studies
Do: Evaluate, Assess & Discuss Various Case Studies
L.O.T.: Evaluating
© 2011 McGraw-Hill Higher Education. All rights reserved
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
© 2011 McGraw-Hill Higher Education. All rights reserved
NEW VOCAB WORD Get out your vocab sheet
© 2011 McGraw-Hill Higher Education. All rights reserved
ASSUMPTION OF RISKDefinition:
The individual, through express or implied agreement, assumes that some risk or danger will be involved in the particular undertaking.
© 2011 McGraw-Hill Higher Education. All rights reserved
ASSUMPTION OF RISKUses/ Elaboration:
A person takes his/ her own chances
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ASSUMPTION OF RISK
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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.
© 2011 McGraw-Hill Higher Education. All rights reserved
Equipment warning labelsInforms of possible dangers with
product useNational Operating Committee on
Standards for Athletic Equipment (NOCSAE)Minimum standards for equipment to ensure safety
© 2011 McGraw-Hill Higher Education. All rights reserved
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
© 2011 McGraw-Hill Higher Education. All rights reserved
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
© 2011 McGraw-Hill Higher Education. All rights reserved
OBJECTIVETopic: Insurance Considerations
Do: Identify General Health Care & Insurance
L.O.T.: Remembering
© 2011 McGraw-Hill Higher Education. All rights reserved
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
© 2011 McGraw-Hill Higher Education. All rights reserved
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
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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
© 2011 McGraw-Hill Higher Education. All rights reserved
PROFESSIONAL LIABILITY INSURANCE
Covers claims of negligence on the part of the individual
Covers negligence on a civil case not criminal
© 2011 McGraw-Hill Higher Education. All rights reserved
CATASTROPHIC INSURANCECatastrophic injuries in athletics are relatively rare, but are staggering
Organizations (NCAA, NAIA, NFSHSA) provide additional coverage to deal with lifetime extensive care
© 2011 McGraw-Hill Higher Education. All rights reserved
INSURANCE VIDEOHandout video questions
Watch and answer questions
Will go over after video
© 2011 McGraw-Hill Higher Education. All rights reserved
INSURANCE VIDEO
http://www.khanacademy.org/science/healthcare-and-medicine/v/healthcare-system-overview
© 2011 McGraw-Hill Higher Education. All rights reserved
INSURANCE VIDEO ANSWERSProvidersInsurersEmployers & PatientsHMOPPO
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BELLWORKIn 12 words or less why do you think an athlete should have general insurance?
© 2011 McGraw-Hill Higher Education. All rights reserved
OBJECTIVETopic: Third Party Reimbursement & Billing
Do: Classify and Evaluate Different Insurances
L.O.T.: Evaluating
© 2011 McGraw-Hill Higher Education. All rights reserved
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
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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
© 2011 McGraw-Hill Higher Education. All rights reserved
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
© 2011 McGraw-Hill Higher Education. All rights reserved
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
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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
© 2011 McGraw-Hill Higher Education. All rights reserved
MEDICARE & MEDICAIDMedicare:
Federal Health Insurance for the aged & disabled
Medicaid:People with low incomes or limited resources
Combination of federal and state
© 2011 McGraw-Hill Higher Education. All rights reserved
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
© 2011 McGraw-Hill Higher Education. All rights reserved
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)
© 2011 McGraw-Hill Higher Education. All rights reserved
ASSIGNMENT: INSURANCE SCENARIO
Get Scenario HandoutAnswer questions (Yes, No & Why)
Discuss
© 2011 McGraw-Hill Higher Education. All rights reserved
PLANGet Unit 3 WorksheetReview for Unit 1, 2 & 3 Test next class period
Unit 1-3 Test day after