chapter 3 - legal concerns and insurance issues

ethical standards relevant to AT

NATA Code of Ethics 1. Members shall respect the rights, welfare, and dignity of all individuals a. No discrimination b. Commitment to competent care consistent with requirements & limitations of profession c. Preserve confidentiality of privileged information and do not release such information to a 3rd party not involved in patient's care, unless consent is given 2. Members shall comply with laws & regulations governing athletic training a. Local, state, & federal laws & institutional guidelines b. Be familiar & adhere to all NATA guidelines & ethical standards c. Report illegal or unethical practice pertaining to athletic training d. Avoid substance abuse 3. Maintain & promote high standards in the provision of services a. Recognize need for continuing education and participate in continuing education b. Be fair, considerate, and equitable when evaluating performance of other staff members (have an established criteria) c. Share evaluations of other staff members with those individuals d. Educate those you supervise (AT px & ethical px) e. When possible participate & support research and education f. Researchers or educators are responsible for maintaining & promoting ethical conduct in those settings 4. Do not engage in any form of conduct that constitutes a conflict of interest or that adversely reflects on the profession a. Private conduct is a personal matter except when such conduct compromises the fulfillment of professional responsibilities b. Do not use NATA logo for self promotion c. Do not place financial welfare above patient welfare d. Able to seek financial compensation for services that is commensurate with their services and in compliance with applicable law

claims processing in educational settings

Preliminary steps to make filing easier: o Gather insurance information for every student-athlete (during PPE - should be updated annually) o Communicate by letter with the parents of all student-athletes Inform them of the limits of the schools' accident insurance policy and the steps they will need to take to process an insurance claim Secondary coverage - explain that parents must submit all medical bills to their insurance company before submitting the balance to the school o Create a file for each student (color code for status of claim - not yet submitted, not yet paid, closed) o Enter each claim on a insurance claim registry form - worksheet that aids in tracking the progress of an insurance claim through the entire process (date filed, name, insurance company, amount due, amount paid, date paid) • Do not submit claims to secondary insurance company before receiving an explanation of benefits form (EOB): summary prepared by an insurance company and set to a policyholder that documents how the insurance policy covered the charges associated with a particular claim • HMOs have become the predominant form of health insurance available o Managed care: concept that emphasizes cost control through coordination of medical services o Student may be required to see treatment from physician designated as his/her primary care provider (acts as first source of medical service, correct agent of referral to be reimbursed by company) Contact HMO & request procedure to be followed in the event of an athletic accident (learn limitations and rules for each policy) Place an "HMO ALERT" label on athlete's medical record Determine if HMO will assign a physician in the local college community as the student's primary care provider during the time the student is in school If school's secondary coverage plan will not cover claims rejected by HMO for noncompliance, be sure to remind parents of that fact • Things to avoid: o Obtain patient insurance information early o Never convey the impression that the institution will pay all expenses involving athletic injuries o Do not take primary responsibility for filing claims with student's personal insurance company o Do not prepay medical vendors from the athletic budget o Do not delay in filing claims with primary or secondary insurers (many policies have time limits) o Communicate with parents to ensure that all medical bills have been filed with insurance company o Do not submit incomplete claims

certification

a form of title protection, established by state law or sponsored by professional associations, designed to ensure that practitioners have essential knowledge and skills sufficient to protect the public

tort

a legal wrong, other than breach of contract, for which a remedy will be provided, usually in the form of monetary damages - actions will be pressed by plaintiffs in civil legal proceedings (criminal cases initiated by government) - 3 types: intentional tort, negligent tort, and strict liability tort

exemption

a legislative mechanism used to release members of one profession from the liability of violating another profession's practice act (typical- physical therapy, physician assistant, medical & masseuse practice acts) - least restrictive form of professional regulation; ATs may still be required to meet certain standards - Colorado, Hawaii, Utah, Wyoming

code of ethics

a systematized set of standards or principles that defines ethical behavior appropriate for a profession; moral values determine the standards and principles - provides a guide to appropriate conduct for members - provides a reference by which to judge members whose conduct comes into question - provides assurance and protection to the public served by members of the profession

primary coverage

a type of health/medical/accident insurance that beings to pay for covered expenses immediately after a deductible has been paid - athlete's personal insurance is not a source for payment of medical bills from athletic participation - institutions adopt such plans because: > feel a moral obligation to pay for medical expenses without involving families & their insurance > may have a student population that is substantially uninsured anyway (logical) > primary coverage simplifies and accelerates claims processing (family isn't involved) > expensive!! (institution pays a much higher premium because insurance company takes on ALL risk) > very few educational institutions use this policy advantages = sense of responsibility, simplified claims process, logical choice for a larger percentage of uninsured athletes disadvantage = expense

damage

a. An actual adverse outcome exists i. Physical, mental, lost wages or tangible benefits, pain and suffering, many others... ii. Emotional distress, loss of consortium (injury to the marital relationship)

breach of duty

a. Must show the athletic trainer breached a duty owed to patient b. Whether or not athletic trainer exercised the standard of care that other reasonably prudent ATs would have exercised under circumstances i. Compare actions to those of other athletic trainers in: 1. The same locality 2. Similar communities 3. The same or similar circumstances ii. The standard of care the AT is held to depends on whether the state has credentialed the profession (otherwise may be held to standard of care of other regulated professionals)

causation

a. Plaintiff must prove that the breach was the legal cause of the injury (or made injury worse) b. Two types of cause i. Actual cause: the degree to which a health care practitioner's actions are associated with the adverse outcomes of a patient's care 1. Coaches, physicians, or institutions may be named as codefendants 2. Severable liability: several people contributed to harm and percentage of harm is distributed among people involved 3. Joint liability: several people contributed to different levels, all pay the same ii. Proximate (legal) cause: the degree to which the harm caused by a health care practitioner was foreseeable (projectability of the likely outcome of an act) 1. ATs are not penalized for results that were improbable or unlikely

existence of duty

a. at educational institutions: duty to provide services to athletes actively engaged in the institution's athletic programs i. duty to intramural sports participants depends on contract b. provide or obtain reasonable medical assistance i. ASAP under circumstances in order to avoid aggravation of injury 1. Effective emergency action plan a. Necessary first-aid supplies b. Communications with ambulance services c. maintain confidentiality of medical records d. provide adequate and proper supervision and instruction (use established protocols) e. provide safe facilities and equipment f. fully disclose information about the individual's medical condition to the individual i. long term consequences g. Abandonment: desertion of a patient-practitioner relationship by the health care provider without the consent of the patient i. Only okay to discontinue services when: 1. Practitioner provides adequate time to find alternative services 2. Jointly terminate relationship (full recovery) 3. Patient voluntarily terminates treatment (documentation, AT tells consequences) ii. If AT leaves patient in the care of another practitioner for vacation, for example, can be charged for negligence (get patient agreement to see another practitioner)

reducing risk of litigation

coach: warn athletes of potential dangers in sport, supervise regularly and attentively, properly prepare and condition athletes, properly instruct athletes in the skills of their sports, ensure proper & safe equipment & facilities are used by athletes at all times athletic Trainer: - build relationships - insist on a written contract for work - obtain informed consent > warn athletes of dangers - provide physical examinations > make sure content and frequency meet standards - know the profession and its standards - participate in continuing education - make a documented attempt to avoid injury by removing or modifying potential hazards - establish policies - document activities - maintain confidentiality - provide proper instruction - supervise your staff - recognize your qualifications / limitation

CPT (current procedural terminology)

coding system applied to specific medical procedures to standardize the language associated with third-party reimbursement

policy

contract between an insurance company and an individual or organization

medical insurance

contract between policyholder and insurance company to reimburse a percentage of the cost of the policyholder's bills (usually after policyholder has paid a deductible

fraud

criminal misrepresentation for the purpose of financial gain - AT should never change the date of an injury, treatment, or assessment, or fail to record payments form an insurance company on a patient's bill - other types of fraud: claiming reimbursement for treatments that were never performed, increasing charges for treatments for patients with insurance

claims processing in sports medicine clinics

different from educational institutions: - AT must integrate claims processing within the context of a larger patient billing system > Livelihood of clinic depends on ability to secure a steady flow of referrals from primary care physicians and specialists Clinics receive direct payments from third-party payers ATs face a greater accounting burden than those working in educational institutions CMS 1500: form that private-practice clinics should use when filing a claim; originally developed for Medicare UB-92/CMS 1450: insurance claim form that hospitals should use Electronic data interchange (EDI): system whereby insurance claims can be submitted electronically; also known as paperless claims system

type of third party players

fee-for-service/ indemnity plan health maintenance organization (HMOs) individual practice association (IPA) preferred provider organization (PPOs) exclusive provider organization (EPO) point-of-service plan (POS) medicare medicaid CHAMPUS

licensure

form of state credentialing, established by statute and intended to protect the public, that regulates the practice of at trade or profession by specifying who may practice and what duties they may perform most restrictive form of governmental credentialing usually requires a specific educational background and passing a licensing examination ( boards decide who may practice; set fees required for license applications and renewals

forbidden knowledge

information about a situation that an athletic trainer is forbidden to act on do not agree to terms such as "if I tell you this, you must promise not to share it with anyone" - insist that the patient offering it trust her to act in the patient's best interests > if patient is unable to accept terms, refer him/her and strongly suggest that he/she follow through with it - can offer to use information in an anonymous fashion offering of forbidden knowledge is a common avenue by which an AT is at risk for being manipulated (shrewdly or deviously influencing or controlling another person or a situation) - act on information cautiously; possibly delay action until info can be verified

assumption of risk

injured plaintiff understood the risk of an activity and freely chose to undertake the activity regardless of the hazards associated with it two conditions must be met: 1. Athlete must "fully appreciate" the type and magnitude of risk involved in participating in activity 2. Athlete must "knowingly, voluntarily, and unequivocally" choose to participate in the face of risk may be accomplished through: - Waiver signed by athlete or his/her parents • Athlete/parents have been warned of the dangers associated with sport • Athlete/parents understand risks • Athlete/parents have been offered the opportunity to ask questions regarding risks • Athlete/parents voluntarily choose to participate regardless of risks - Difficult when dealing with minors > Usually courts uphold waivers and releases of liability for adults unless there is evidence of fraud, misrepresentation, or duress

self-insurance

institutions with this type are speculating that the amount they pay out for medical expenses will be less than the amount they would pay for insurance premiums - only purchase catastrophic coverage and pays medical bills incurred by student-athletes - NCAA have rules that prevent institutions from paying for medical expenses not directly related to sport advantages = potential savings, simple claims process, flexibility disadvantage = high risk for larger claims, institutional dollars tied up

catastrophic insurance

insurance designed to provide lifelong medical, rehabilitation, and disability benefits for the victims of a devastating injury usually takes effect after the first $25,000 in medical bills has been reached - member institutions of the NCAA have received catastrophic insurance at no cost since 1991 National Federation of State High School Associations (NFSHSA) provides medical, rehabilitation, and transportation costs in excess of $10,000 not covered by other insurance benefits costs for catastrophic insurance is based on: - number of sports offered by institution - number of hazardous sports offered by institution

secondary coverage

insurance that begins to pay for covered expenses only after all other sources of insurance coverage have been exhausted; also known as excess insurance - most common choice for educational institutions - institution lowers cost by sharing risk of injuries to other potential payers (60% lower than primary) - develops a sense of shared responsibility for safety in an athletic program > parents are even more interested in safety of children when they have a financial interest - encourages athletic administrators to find ways to reduce and control medical costs - claims processing takes more time & effort (communication with parents and their insurance carriers) - requires more communication and understanding about shared responsibility of paying medical costs advantage = less costly, shared responsibility disadvantages = longer and labor intensive claims process, requires more communication

product liability

liability of any or all parties along the chain of manufacture of any product for damage caused by that product (manufacturer of component parts, assembling manufacturer, wholesaler & retail store owner) - faulty design - faulty construction - failure to provide adequate warning - failure to conform to an express warranty

malpractice

liability-generating conduct associated with the adverse outcome of patient treatment

professional liability insurance

only covers athletic trainer in civil cases (not criminal) claims made (cheapest): only covers claims made during the calendar year tail coverage: covers things outside of the policy year occurrence policy: covers any incident during the policy year not just limited to work related situations recommended liability limits - $1,000,000 per occurrence - $3,000,000 annual aggregate

knowledge of high risk behaviors

patient may be at risk due to his/her own behaviors, or he/she may be putting others at risk ethical responsibility: make sure individual is aware of associated risks of his/her behaviors, assist person in finding alternative to high-risk behaviors when behavior puts others at risk, AT has responsibility to intervene (at least warn those being put at risk)

strict liability

patient using its product is injured, regardless of the foreseeability of risk or the care the manufacturer took to prevent an injury

primary party

person directly involved as a participant in an activity most menacing ethical issues will be those in which the AT is a primary party to the ethical concern behaving in an ethically questionable manner or being the victim of an unethical act

deductible

portion of any claim that is not covered by the insurance provider; the amount of expenses that must be paid out of pocket before an insurer will cover any expenses

credentialing

practice acts define different roles and responsibilities for athletic trainers and students - different scopes of practice, allowability to charge fees, limitations on use of therapeutic modalities, specific educational requirements; most require physician supervision states without credentialing for athletic training - follow the state's medical practice act (state law regulating the practice of medicine, usually by specifying who many practice and under what circumstances)

UCR

reduce likelihood of having claim denied by making sure referred provider will perform only nonexperimental procedures and that they will accept the UCR fee as payment in full for services rendered. ways to resolve claims denied due to experimental treatment or UCR causes: - find out exact reason for which the claim was denied - obtain a statement from provider explaining why treatment was implemented & justifying the fee - correspond with the employer who provides the self-insurance fund (has authority to reverse denial) - provide evidence from clinical studies to support your claim that tx should not be viewed as experimental - try to convince provider to waive portion of fee above the UCR amount - contact state insurance commissioner and request assistance in challenging denial

experimental therapy

terms of most insurance policies exclude experimental treatments (therapies not yet proved effective) insurance industry often determines that a therapeutic method has made the transition from experimental to conventional several years after the medical industry does companies define experimental in various ways: - list in the policy what they consider experimental procedures - list the criteria by which they will determine if a procedure is experimental (less exact, poor defense) - decide on a case-by-case basis (can be frustrating for patients and health care providers)

usual, customary, and reasonable (UCR)

the charge consistent with what other medical vendors would assess - factors that determine the amount of money companies will pay: > usual fee for service charged by each health care provider > customary fee for geographic area (the lowest of either average fee or 90th percentile fee, the fee below which 90% of all other medical vendors charge for a service) > reasonable fee (lower of either usual or customary fee)

comparative negligence

the degree to which a plaintiff contributed to the harm caused by a defendant - examples: failing to follow instructions, failing to perform rehabilitation - court determines the degree (%) to which the AT and plaintiff contributed to the harm > plaintiff recovers the percentage of how much the defendant was to blame for negligence > in most states, patient can collect damages only if comparative negligence is <50% of total

third-party reimbursement

the process by which medical vendors receive reimbursement from insurance companies for services provided to policyholders insurance companies have been slow to cover athletic trainer's services - becoming more available as more states credential athletic trainers seeking of third-party reimbursement from college student-athlete's personal insurance companies is frowned upon (creates the feeling that ATs might prioritize treatment based on insurance coverage)

ethics

the rules, standards, and principles that dictate right conduct among members of a society or profession; based on moral values (represent norms of social interaction and have been influenced by religion)

third party

to be affected by, but not directly involved in, a situation. Professionals who simply have knowledge of an unethical act can be affected by it, because they have a professional responsibility to act as a third party participant, the AT can more appropriately manage a solution to the situation conflicts may occur between the professional's responsibility to maintain confidentiality, her responsibility to protect the patient from harm, her responsibility to protect others from harm, and other loyalties she might have that affect the patient

health maintenance organizations (HMOs)

type of insurance plan that requires policyholders to use only those medical vendors approved by the company. All medical services are coordinated by a primary care physician, who acts as a gatekeeper to specialty services - determination of fees is usually accomplished by a capitation system (vendors received a fixed amount per patient) - some HMOs provide services at medical facilities, whereas others provide care through a network of individual medical practitioners

registration

type of state credentialing that requires qualified members of a profession to register with the state in order to practice (some allow a grace period during which AT may practice without being registered) - prohibits unregistered persons from practicing, it becomes a form of title protection for the athletic trainer - states that require registration may or may not require screening devices (i.e. examinations) - Kansas, Minnesota, Missouri, Oregon

fee-for-service/ indemnity plan

type of traditional medical insurance whereby patients are free to seek medical services from any provider; plan covers a portion of cost of covered procedures & patient is responsible for the balance

name protection

unlicensed individuals are not allowed to call themselves athletic trainers

service protection

unlicensed individuals are not allowed to perform tasks reserved for ATs under law

exploitation

use of another person for selfish purposes - bribing of athletes - manipulating athlete to play when injured - selling of items (legal/illegal) to athletes for financial gain

diagnostic and procedural coding

using improper codes will significantly increase time required by insurance company to process claim and might result in denial of claim ICD-9-CM CPT

state certification

usually only protects an athletic trainer's title, not the specific tasks and he/she performs - noncertified persons could not call themselves athletic trainers, but they could perform the duties of a AT - Kentucky, Louisiana, New York, Pennsylvania, South Carolina, Virginia

exclusive provider organization (EPO)

variant of PPO medical serves are reimbursed only if patient uses contracted providers

breach of confidentiality

violation of a commitment to privacy and protection of information or communications exceptions to the rule of confidentiality: - reason: the basis or explanation for an action; excuse: a reason that is considered justifiable - when there is a clear and imminent danger to the client - when there is a clear and imminent danger to the other person - when legal requirements demand that confidential information be released difficult to maintain confidentiality because: - confidential information might be personal, private, and sensitive (handle carefully!) - many people are usually involve dint he care of an athlete - high profile of athletes and of the athlete industry in our society

nonfeasance/ act of omission

when an individual fails to perform a legal duty

misfeasance

when an individual improperly does something they have the legal right to do

conflict of interest

when the interests of one individual or group are in competition with those of another individual or group what are some examples of conflict of interest for ATs? - discussing private information with another party > patient's best interests vs. your job - breach of confidentiality - ATC receiving financial gain to utilize a particular product - allocation of resources for head/supervising ATC what can the AT do to avoid breach of confidentiality and conflict of interest situations? - refer the athlete to a counselor > preferably not affiliated with the institution or team

NATA code of ethics

1. Members shall respect the rights, welfare, and dignity of all individuals 2. Members shall comply with laws & regulations governing athletic training 3. Maintain & promote high standards in the provision of services 4. Do not engage in any form of conduct that constitutes a conflict of interest or that adversely reflects on the profession

risk reduction strategies

1. Preparation for activity a. Administer PPEs b. Monitor fitness levels c. Assess activity areas d. Monitor environmental conditions 2. Conduct of the activity a. Maintain equipment b. Use proper instructional techniques c. Provide adequate work-rest intervals 3. Injury management a. Have a physician supervise all medical aspects of program b. Evaluate and treat injuries correctly and promptly c. Supervise student athletic trainers 4. Records management a. Document physician orders b. Document the treatment plan c. Document the treatment record d. Document the patient's progress

to prove negligence, plaintiff must prove that the defendant is guilty of 5 components

1. conduct 2. existence of duty 3. breach of duty 4. causation 5. damage

profession

a commitment to certain characteristics that set professionals apart from nonprofessional groups

conduct

a. must prove that AT did something that links him to case (either by omission or commission) b. nonactions (thoughts, attitudes, or intentions) cannot render AT negligent

riders

additions to standard insurance policy that provide coverage for conditions that are not normally covered

standard of reasonable care

assumes that an individual is neither exceptionally skillful nor extraordinarily cautious, but is a person of reasonable and ordinary prudence - adhere to standard of care by adhering to certain standards in the performance of their duties > individual and societal standards > standards derived from institutional and professional values (i.e. position statements)

copayment

capped contribution defined in the policy and paid by an insured person each time a medical service is accessed. It must be paid before any policy benefit is payable by an insurance company

utilitarianism

choosing a course of action that benefits the greatest number of people

ICD-9-CM (international classification of diseases)

coding system applied to illnesses, injuries, and other medical conditions to standardize the language associated with third-party reimbursement

errors and omission liability insurance

designed to cover school employees, officers, and the district against suits claiming malpractice, wrongful actions, errors and omissions, and acts of negligence

claims processing

educational settings: ATs file all (or nearly all) claims with a single insurance company to pay other medical vendors for services rendered to the institution's student athletes sports medicine clinics: ATs file claims with a wide range of insurance companies for reimbursement for services they provide

relationship between legal and ethical considerations

ethical considerations often overlap, contradict, or otherwise interact with issues of law multiple roles that athletic trainers serve makes the issue more difficult (responsible for many types of info)

approaches to ethical decision making

ethical egoism utilitarianism formalism

negligence

failure to act as a reasonably prudent athletic trainer would act under the circumstances (standards of reasonable care)

medicare

government-sponsored program for elderly

CHAMPUS

government-sponsored program for members of armed forces and their dependents

medicaid

government-sponsored program for needy

legal requirements

health care practitioners must obtain signed authorization from a patient for release of medical records be careful when answering insurance company's questions on the telephone (verify identity of caller, make sure patient has signed release authorization before answering questions, requests for detailed explanations should be submitted by the insurance company in writing on the company letterhead)

disability insurance

insurance designed to protect an athlete against future loss of earnings because of a disabling injury or sickness

premium

invoiced cost of an insurance policy

NATA BOC

is the recognized certification agency for ensuring that ATs have basic knowledge and skills to carry out their duties as defined by the Role Delineation Study

knowledge of illegal activities

legal authorities might be aware of activities and seek information from the athletic trainer legal authorities may not be aware of activities athletic trainers with knowledge of illegal activities should seek legal counsel to protect their own status (conflicts of issues of confidentiality, responsibility to client, privileged communication status, legal reporting requirements, and others)

ethical egoism

make decisions that result in greatest benefit to yourself

individual practice association (IPA)

managed-care model whereby an HMO provides health care services through a network of individual medical practitioners. Care is provided in a physician's office as opposed to a large, multifunctional medical center

express warranty

manufacturer's written statement that a product is safe (i.e. label on football helmets)

general health insurance

medical insurance health insurance policy exclusion riders premium deductible copayment

health insurance

more comprehensive; reimburses cost of preventative as well as corrective medical care

accident insurance

most educational institutions buy athletic accident insurance (insurance policy intended to reimburse medical vendors for the expenses associated with acute athletic accidents)

formalism

most likely to be followed by ATs who see a clear professional duty that they believe should be implemented universally

product liability claims can be based on

negligence strict liability breach of warranty of fitness

liability may be based on

negligent patient care failture to obtain informed consent intentional conduct breach of contract use/ transfer of a defective product abnormally dangerous treatment

types of negligence

nonfeasance/act of omission malfeasance/ act of commission misfeasance

breach of warranty of fitness

product is found to be unfit for the purpose for which it was intended

intent

protect the public by limiting the practice of AT to those who have met requirements of a licensing board established under the law

Good Samaritan Law

provides limited protection against legal liability to any person who voluntarily chooses to provide first aid - not able to be used by AT in work setting (a higher trained person held to higher standards) - may be possible to use in volunteer setting > no duty to person in volunteer setting

negligence

risk of injury from use of product was foreseeable & company did not exercise due care in reducing or eliminating risk

knowledge of conflicting interests

self-determination: free will to judge for oneself, to determine one's own course of action, and to manage one's own affairs seek permission to take action or disclose information bring involved parties together to develop a mutually acceptable solution to problem - allows each party to become familiar with perspective of other party

types of athletic insurance

self-insurance primary coverage secondary coverage

statute of limitation

sets a specific length of time that individuals may sue for damages from negligence in general, plaintiffs have 1-3 years to apply for negligence some states allow an injured minor to file suit up to 3 years after the minor reaches age 18

point-of-service plan (POS)

similar to PPOs, except that primary care physicians are assigned to patients to coordinate their care

exclusions

situations or circumstances specifically not covered by an insurance policy

sovereign immunity

states that neither the government nor any individual who is employed by the government can be held liable for negligence

liability

the state of being legally responsible for the harm one causes another person

preferred provider organization (PPO)

type of insurance plan that provides financial incentives to encourage policyholders to use medical vendors approved by the company - compared to HMOs: allow a greater choice of medical vendor, pay vendors on a fee-for-service basis - patients who see vendors outside the preferred network will pay a higher percentage of costs

malfeasance/ act of commission

when an individual commits an act that is not legally his to perform