BELLWORK
 Get
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
 Torts
 Nonfeasance
 Malfeasance
 Misfeasance
© 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
OBJECTIVE
Topic:
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 TRAINER
Lawsuits
have become the rule
rather than the exception
Athletic trainers are held
accountable for their patient
care
 What
they do and don’t do
© 2011 McGraw-Hill Higher Education. All rights reserved
NEW VOCAB WORD
Receive
a new unit vocabulary
sheet
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LIABILITY
Definition
 The
state of being legally
responsible for the harm one
causes another person
© 2011 McGraw-Hill Higher Education. All rights reserved
LIABILITY
Uses/
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
NEGLIGENCE
 Definition
The failure to use ordinary or
reasonable care

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NEGLIGENCE
 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

© 2011 McGraw-Hill Higher Education. All rights reserved
NEGLIGENCE
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DUTY OF CARE
 Definition
Part of the official job
description

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DUTY OF CARE
 Uses/
Elaboration:
What the person is suppose to
do

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DUTY OF CARE
© 2011 McGraw-Hill Higher Education. All rights reserved
TO PROVE NEGLIGENCE
Duty
to Care
Breach of duty (Conduct
fell short)
Damages (Injury/ $)
© 2011 McGraw-Hill Higher Education. All rights reserved
THINK, PAIR, SHARE
 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
© 2011 McGraw-Hill Higher Education. All rights reserved
BELLWORK
What
are the 3 things one must
prove in order to successfully sue
for negligence?
 Duty to Care
 Beach of Duty
 Damages
© 2011 McGraw-Hill Higher Education. All rights reserved
OBJECTIVE
Topic:
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
TORTS
Definition:
 Legal
wrongs committed
against a person or property of
another
© 2011 McGraw-Hill Higher Education. All rights reserved
TORTS
Uses/
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
NONFEASANCE
 Definition:

When an individual fails to perform a
legal duty
© 2011 McGraw-Hill Higher Education. All rights reserved
NONFEASANCE
 Uses/
Elaboration:
Also known act of omission
 They do not do something they are
suppose to do

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NONFEASANCE
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MALFEASANCE
Definition:
 An
individual commits an act
that is not legally his to
perform
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MALFEASANCE
Uses/
Elaboration:
 Act
of commission
 Doing something outside of their
duty
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MALFEASANCE
© 2011 McGraw-Hill Higher Education. All rights reserved
MISFEASANCE
 Definition:

An individual improperly does
something he or she has the legal
right to do
© 2011 McGraw-Hill Higher Education. All rights reserved
MISFEASANCE
 Uses/

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 NEGLIGENCE
 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
© 2011 McGraw-Hill Higher Education. All rights reserved
OTHER LEGAL ASPECTS
 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
© 2011 McGraw-Hill Higher Education. All rights reserved
LEGAL PROTECTION*
NEW VOCAB
Sovereign
Immunity
Good Samaritan Law
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NEW VOCAB WORD

Get out your vocab sheet
© 2011 McGraw-Hill Higher Education. All rights reserved
SOVEREIGN IMMUNITY
 Definition:

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 IMMUNITY
 Uses/
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 LAW
Definition:
 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 LAW
Uses/
Elaboration:
 Acts
within their education and
gives reasonable care
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GOOD SAMARITAN LAW
© 2011 McGraw-Hill Higher Education. All rights reserved
SCENARIO- BASEBALL LAWSUIT
Receive
Baseball Lawsuit
Scenario
Answer Yes, No & Why
© 2011 McGraw-Hill Higher Education. All rights reserved
BELLWORK
Define
in your own words:
 Nonfeasance
 Malfeasance
 Misfeasance
© 2011 McGraw-Hill Higher Education. All rights reserved
OBJECTIVE
Topic:
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 RISK
Definition:
 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 RISK
Uses/
Elaboration:
A
person takes his/ her own
chances
© 2011 McGraw-Hill Higher Education. All rights reserved
ASSUMPTION OF RISK
© 2011 McGraw-Hill Higher Education. All rights reserved
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
equipment
 Invalidates the manufacturers warranty
 Liability solely on the athletic trainer, coach,
etc.
© 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
© 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 worksheet
 Each group will give a short
presentation on what the case was
and answers to the worksheet
© 2011 McGraw-Hill Higher Education. All rights reserved
BELLWORK
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
© 2011 McGraw-Hill Higher Education. All rights reserved
OBJECTIVE
Topic:
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 policyholder
 Insurance 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
© 2011 McGraw-Hill Higher Education. All rights reserved
ACCIDENT INSURANCE
 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
© 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 INSURANCE
Catastrophic
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 VIDEO
Handout
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/healthcareand-medicine/v/healthcare-system-overview
© 2011 McGraw-Hill Higher Education. All rights reserved
INSURANCE VIDEO ANSWERS
Providers
Insurers
Employers
& Patients
HMO
PPO
© 2011 McGraw-Hill Higher Education. All rights reserved
BELLWORK
In
12 words or less why do you
think an athlete should have
general insurance?
© 2011 McGraw-Hill Higher Education. All rights reserved
OBJECTIVE
Topic:
Third Party
Reimbursement & Billing
Do: Classify and Evaluate
Different Insurances
L.O.T.: Evaluating
© 2011 McGraw-Hill Higher Education. All rights reserved
THIRD- PARTY
REIMBURSEMENT
 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
© 2011 McGraw-Hill Higher Education. All rights reserved
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 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
© 2011 McGraw-Hill Higher Education. All rights reserved
OTHER
 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
© 2011 McGraw-Hill Higher Education. All rights reserved
MEDICARE & MEDICAID
Medicare:
 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 claim
 Must 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
97116
Athletic trainer evaluation and
reevaluation (per visit)
Physical performance test (each 15
minutes) treatment charges
Gait training (each 15 minutes)
97110
Therapeutic exercise (each 15 minutes)
97112
Neuromuscular reeducation (each 15
minutes)
Therapeutic activities (each 15 minutes)
97750
97530
97113
97124
97530
97140
Aquatic therapeutic exercise (each 15
minutes)
Massage (each 15 minutes)
Body mechanics training (each 15
minutes)
Manual therapy (each 15 minutes)
© 2011 McGraw-Hill Higher Education. All rights reserved
ASSIGNMENT: INSURANCE
SCENARIO
Get
Scenario Handout
Answer questions (Yes, No &
Why)
Discuss
© 2011 McGraw-Hill Higher Education. All rights reserved
PLAN
Get
Unit 3 Worksheet
Review for Unit 1, 2 & 3 Test
next class period
Unit 1-3 Test day after
© 2011 McGraw-Hill Higher Education. All rights reserved