Chapter 3

Filing an Insurance Claim

Two Types of billing codes which must be filed when submitting a claim on standard HFCA-1500 or UB-92 forms

Professional liability insurance

Typically covers negligence in a civil case

2005 CMS ruling

a ruling stating that they would "no longer pay for therapy 'incident to' a physician's services unless the provider is a physical therapist, occupational therapist or speech/language pathologist"

Medicare Part C

allows a person to choose among several types of health care plans, including medical savings accounts, managed care plans and private fee-for-service plans

Standard of Reasonable Care

an individual is neither exceptionally skillful nor extraordinarily cautious, but is a person of reasonable and ordinary prudence. An athletic trainer will act according to the standard of care of an individual with similar educational background or training

Physicians are not able to

bill Medicare for treatment provided by athletic trainers

Medical insurance

contract between an insurance company and a policyholder in which the insurance company agrees to reimburse a portion of the total medical bill after some deductible has been paid by the policyholder

Medicare Part A

hospital portion, normally premium free at retirement to the beneficiary

increase in lawsuits =

increase in medical costs (1971)

NFSHSA can provide

medical, rehabilitation, and transportation costs in excess of $10,000 not covered by other insurance benefits

What does the Policyholder's insurance company do?

reimburses health care professionals for services performed

Medicare Part B

the physician portion, has a monthly premium charge to the beneficiary

When do Benefits begin ?

when expenses reach $25,000 and are then extended for a lifetime

Third-Party Reimbursement for Athletic Trainers

•1995 NATA established the reimbursement advisory group to monitor managed care changes and to help the athletic trainer secure a place as a health care provider •1996 NATA initiated the athletic training outcomes assessment project designed to present supporting data that measures the results of interventions involving athletic training procedures •Licensure is the key to successful reimbursement from third party payers

Third Party Administrators (TPA's)

•Administer services and to pay claims for self-insured group plans and thus function as pseudo insurance companies •Provide services such as enrollment and billing

Assumption of Risk

•Athlete assumes risk of participating in an activity •Subject to varied interpretations by courts, especially when a minor is involved

Point of Service Plan (POS)

•Combination of HMO and PPO plans •Based on HMO structure, but allow members to go outside the HMO to obtain services

Exclusive Provider Organizations (EPO)

•Combination of HMO and PPO plans •Restrictive in the number and type of providers they have and consequently are more like HMO's and will not pay if out of network providers are used

Medicaid

•Health insurance program for people with low incomes and limited resources •Funded by both the federal government and individual states, benefits vary from state to state

Physician Hospital Organization (PHO)

•Involve a major hospital or hospital chain and its MD's •Contracts directly with employers to provide services and/or contracts with a managed care organization

Workers Compensation

•Laws and benefits for injured workers are mandated by the states •Employers pay the premiums and the claims are settled by workers compensation insurance carriers •Want to return the injured worker to the work force as soon as possible

Product Liability

•Manufacturers have a duty to design and produce athletic equipment that will not cause injury as long as it is used as intended •If an athletic trainer alters equipment in anyway, it invalidates the warranty •NOCSAE establishes minimum standards for football helmets to ensure safety

Indemnity Plans

•Most traditional form of billing for health care •Fee-for-service plan that allows the insured party to seek medical care without restrictions on utilization or cost. •Charges are based on a set fee schedule

Preferred Provider Organizations (PPO's)

•Provide discount health care but also limit where a person can go for treatment •Pay on a fee-for-service basis

Health Maintenance Organizations (HMO's)

•Provide preventive measures and limit where the individual can receive care •Except in emergencies, permission must be obtained before the individual can go to another provider •Generally pay 100% of the medical costs as long as care is rendered at an HMO facility

Reducing the Risk of Litigation

•Work to establish good personal relationships •Establish policy and procedures •Develop emergency action plan •Become familiar with medial history of athletes •Keep accurate records and document injuries and rehabilitation •Have detailed job description in writing •Obtain written consent from minors parents or guardians •Maintain confidential medical records •Exercise precaution in dispensing non-prescription drugs •Use only therapeutic methods qualified to use •Do not allow faulty or hazardous equipment to be used •Work w/ coach and MD on selection of sports protective equipment •Do not permit injured players to participate unless cleared by MD •Do not allow an injured player to reenter competition until he/she is psychologically and physically able •Follow orders from team MD at all times •Purchase professional liability insurance •Know limitations of expertise and know state regulations and restrictions to scope of practice •Use common sense in making decisions about a patient's health and safety

Current Procedure Terminology Code

(CPT code) - Identifies specific medical procedures used in treating a patient (i.e. 97035 = ultrasound each 15 min)

Diagnostic code

(ICD-9-CM) - Five digit code that specifies the condition or injury that is being treated (i.e. code 845.02 = calcaneofibular ligament sprain in ankle)

Malfeasance

(act of commission) An individual performs an act that is not legally his to perform; An athletic trainer suturing a laceration, Fitting an athlete with a helmet that is too large for them, leading to serious injury

Nonfeasanc

(act of omission) An individual fails to perform a legal duty; failure to refer an injured athlete to MD

Liability

Being legally responsible for the harm one causes another person

CMS

Centers for Medicare and Medicaid Services

Managed care

Costs of a health care provider's medical care are closely monitored by insurance carriers

Errors and omissions liability insurance

Designed to cover school employees, officers and the district against suits claiming malpractice, wrongful actions, error and omissions, and acts of negligence.

Three things needed to establish negligence:

Duty of care, Conduct of defendant fell short of that duty or care and resultant damages.

Negligence

Failure to use ordinary or reasonable care

Federal government does not recognize

Federal government does not recognize

Medicare

Federal health insurance program for the aged and disabled

Medicare Part D

Federal program to subsidize the costs of prescription drugs for Medicare beneficiaries went into effect in 2006, beneficiaries can either join a prescription drug plan (PDP) for drug coverage only or they can join a Medicare Advantage Plan (MA) that covers both medical services and prescription drugs.

Capitation

Form of reimbursement used by managed care providers in which members make a standard payment each month regardless of how much service is rendered to the member by the provider

Family health insurance

Insurance provided by an individual through a family member

Sovereign Immunity

Legal document that states that neither the government nor any individual who is employed by the government can be held liable for negligence - level of protection from sovereign immunity varies from state to state

Torts

Legal wrongs committed against the person or property of another

Catastrophic insurance

NCAA and NAIA provide plans that deal with the problem of a lifetime that requires extensive medical and rehabilitative care because of a permanent disability from sports participation

NFSHSA stands for

National federation of state high school associations

When is Negligence alleged?

Negligence is alleged if an individual does something a reasonably prudent person would not do or fails to do something a reasonably prudent person would do in similar circumstances

Secondary insurance

Pays the remaining medical bills once the personal insurance company has made its payment

Statutes of Limitation

Plaintiffs have between 1-3 years to file a suit of negligence, either from time of incident/omission or from the time of discovery of injury caused by the negligent act or omission.

General health insurance

Policy that covers illness, hospitalization and emergency care. (secondary insurance coverage, family health insurance)

Good Samaritan Law

Provides limited protection against legal liability to any individual who voluntarily chooses to provide first aid, should something go wrong

Good Samaritan law

Provides limited protection against legal liability to any person who voluntarily chooses to provide first aid.

How To prove negligence

To prove negligence must prove that the athletic trainer had a duty to exercise reasonable care, that the athletic trainer breached that duty by failing to use reasonable care and that there is a reasonable connection between the failure to use reasonable care and the injury the individual suffered, or that the athletic trainers action made the injury worse