| Legal consideration in Sports Medicine - Practicing athletic trainers and students need to be familiar with the practice acts that regulate the profession - Roles and responsibilities defined by law are likely to be different for practicing athletic trainers and students - Practice Acts vary according to State o The definition of athlete and athletic trainer are different o Some allow athletic trainers to “change a fee for service” other do not o Some limit types of therapeutic modalities athletic trainers may use o Most have educational requirements but might not be related to requirements for NATABOC certification o The major city of state laws require athletic trainers to be supervised by a physician Medical Practice Act - A state law that regulates the practice of medicine, usually by defining the o Scope of practice o Setting of practice o Supervision requirement o Credentialing Risk Management - Process to prevent all kinds for everyone in the organization (e.g. directors, administrator, employees, and client) - Risk Identification o Obvious risk factor o Risk of playing surface on injuries o Real-world observation o Making inference regarding risk of certain activities based on clinical practice and experience o Controlled Experience § Data driven studies Reducing Risk in Athletics 1. Preparation for the activity a. Physical exam b. Fitness level c. Assess activity areas d. Monitor environment 2. Conduct of the activity a. Maintain equipment b. Use proper instructional techniques c. Provide adequate work-rest intervals 3. Injury management a. Supervise all medical aspects of the program b. Evaluate and meet injuries correctly and prompt c. Supervise student AT 4. Records management a. Document physician orders b. Document treatment plan c. Document treatment record d. Document Athlete progress Malpractice - Liability generating violent associated with the adverse outcome of patient care Liability - Responsibility for actives the cause harm to others - Negligent patient care - Failure to obtain informed consent - Intentional conduct - Breach of a contract - Use/transfer of a defective product - Abnormally dangerous treatment Tort - Legal wrong other than breach of contract for which the courts provide some remedy, usually in the form of monetary damage - Civil action rather than criminal - Tort action for malpractice is usually negligence Negligence - Type of tort in which an athletic trainer fails to act as a reasonably product athletic trainer would act under the circumstance through certain standards derived from individual, societal, institutional, and professional values (e.g. policies and procedures, position standards, ACSM, NATA, NCAA) - “With due care” Omission – Failure to do something that should have been done under the circumstances Commission – Performs as act that not have been committed Malfeasance - Individual commits an act that is not their responsibility to perform (e.g. Neck injury is suspected and the football helmet is removed, you could be liable). Misfeasance - Individual commits act that is their responsibility to perform, but uses the wrong procedure or does the right procedure in an improper manner (e.g. Neck injury is suspected and you improperly secure the head and neck to the right spine board, you could be held liable) Nonfeasance - Individual fails to perform their legal duty of care. (If suspect or should have suspected, a neck injury and failed to use a rigid back board Gross negligence – occurs when an individual has total disregard for the safety of others Providing the Athletic Trainer was Negligence - Conduct by the athletic o Must prove act of omission or commission that actually links ATC to the case - Existence of duty o Employment defines duty o Provide services to clients (e.g. teams) o Abandonment/services are chosen to be provide can not quit services without consent of patient § Unless adequate warning and enough time to find alternative care § Patient recovers and is discharged patient voluntarily terminates treatment § Use of a substitute that is competent and patient agrees o Provide reasonable medical assistance o Maintain the confidentially of the patient’s medical records o Provide adequate and proper supervision and instruction o Provide sage facilities and equipment o Fully disclose information about the patient’s medical condition to the patient - Breach of duty o Standard of care – level of medical sophistication and competency that must be demonstrated by someone who has similar education and training to other member of a particular group o Compared to ATC in one these settings (same locality, similar communication, same or similar circumstances) - Causation o Must prove that duty was cause of the injury o Courts use two tests to determine causation § Actual cause – degree to which a health care practitioner’s actions are associated with the adverse outcomes of a patient’s care § Proximate (legal cause – the degree to which the hard caused by a health care practitioner was foreseeable § Foreseeability – ability to project the likely outcome of an act - Damage o The suffered damage § Physical damage is most common § Law however does recognize other dorms of damage (e.g. emotional distress) Legal Defenses for AT - Statute of Limitation - Sovereign Immunity - Assumption of risk - Good Samaritan Immunity Statute of Limitation – Laws that set the length of time that a person may sue for damages under either negligence or malpractice laws Sovereign (governmental) immunity – legal doctrine that neither government nor their agents can be held liable for negligent actions Assumption of risk – attempts to claim that an injured plaintiff understand the risk of an activity and “knowingly voluntarily, and unequivocally” decided to participate regardless Good Samaritan immunity – statutes intended to shield certain health care practitioners from certain types of legal liability when they voluntarily can to the aid of ill person under specific trainers Testimony At a Deposition or Trial Testimony – legally binding statements offered as evidence to the facts in a legal proceeding Deposition – testing taken down in writing under oath Trial – the formed examination before a competent tribunal of the matter in issue in a civil or criminal case in order to determine such issue Subpoena – legal authority used to compel a person to provide testimony Strategies for Avoiding Legal Liability - Build relationships - Insist on a written contract - Obtain informed consent - Provide physical examinations - Know the profession and its standards - Document hazards - Establish policies - Document activities - Maintain Confidentiality - Provide proper instruction - Supervise your staff - Participate in continuing education - Recognize your qualification - Maintain insurance coverage - In general, a plaintiff has between 1 and 3 years to file a negligence suit. This can vary from state to state - It is illegal for an athletic trainer to prescribe and dispense prescription medications Insurance Systems 1. Medical Insurance 2. Health Insurance 3. Athletic accident a. Primary b. Secondary c. Self-insurance 4. Catastrophic insurance 5. Disability - Copayment o A percentage of the total amount the policy holder is required to pay for medical services rendered - Gatekeeper o Appointed by an insurance company to oversee the medical care given to an athlete and is usually a primary care physician - HCFA-1500 form o A standard insurance claim form that is accepted by most insurance carriers. It must be filled out thoroughly for quick reimbursement to be obtained - Medical insurance o A contract between a policyholder and an insurance company to reimburse a percentage of the cost of the policyholder’s medical bills. - Policy o A contract between an insurance company and an individual or organization. o A policy is a broad statement of intended action developed by those who are empowered to govern the operation of an organization. A procedure outlines a specific strategy for members of an organization to follow when following a policy - Health insurance o A type of policy designed to reimburse the cost of preventative as well as corrective medical care. - Athletic accident o A type of insurance policy intended to reimburse medical vendors for the expenses associated with acute athletic accidents. - Accident o Different from athletic trainer and coach perspective and concept of injury: Insurance defines accidents as acute, traumatic injuries, independent of any other cause or preexisting condition, that occur during practices and games. - Exclusions o Situations or circumstances specifically not covered by an insurance policy. - Rider o Additions to a standard insurance policy that provide coverage for conditions that are normally not covered. - Premium o The invoiced cost of an insurance policy. - Catastrophic insurance o A type of accident insurance designed to provide lifelong medical, rehabilitation, and disability benefits for the victims of devastating injury. - Disability insurance o Insurance designed to protect an athlete against future loss of earnings due to a disabling injury or sickness. (NCAA – exceptional in football, men’s basketball and ice hockey.) (NCAA – special assistance fund for medical and dental expense for Division I athletes) - The individual athlete is the only person who can decide whether or not to participate in a sport according to the Americans with Disabilities Act Third-Party Reimbursement - Athletic trainers who work in hospitals and clinics might earn a portion of their incomes through third- party reimbursement. Reimbursement through this system requires knowledge of diagnostic and procedural coding and strict adherence to certain legal requirements on the part of the athletic trainer. - Third-party reimbursement o The process by which medical vendors are reimbursed by insurance companies for services provided to policyholders. - Third-party o A medical vendor with no binding interest in a particular insurance contract. o Third party-medical vendor with no binding interest in a particular insurance contract § Primary process to pay for medical services in the US § Hospitals, medical providers (income) § Athletic trainers (state credentialing) § University program (PT) Types of Third-Party Payers - Private medical insurance companies provide group and individual coverage for employees and their dependents. The medical insurance provided by these companies is typically the traditional fee-for-service plan (indemnity plan). o Fee-for-service plan (Indemnity plan) § A type of traditional insurance whereby patients are free to seek medical services from any provider. The plan covers a portion of the cost of covered procedures, and the patient is responsible for the balance. - Health maintenance organizations (HMO) o A type of health 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 (PC or PCP) who acts as a gatekeeper to specialty services. - Capitation o A system whereby medical vendors are paid a fixed amount per patient. o Must use primary provider (multifunctional facility or individual physicians) that participates in the system - Individual practice association (IPA) o A 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. - Preferred provider organizations (PPOs) o A type of health insurance plan that provides financial incentives to encourage policyholders to use those medical vendors approved by the company. - Exclusive provider organization (EPO) o A type of PPO whereby medical services are reimbursed only if the patient uses contracted providers. - A point-of-service (POS) plan is similar to a PPO. The primary difference between the two is that POS plans assign primary care physician, who act as gatekeepers by coordinating patients care. Most PPO plans do not. - Government-sponsored programs provide coverage for the elderly (Medicare), the needy (Medicaid), and members of the armed forces and their dependents (CHAMPUS). Legal Requirements - Health care practitioners must obtain a signed authorization from patient for release of medical records - Patient-practitioner relationship exists and information must be kept confidential unless patient signs authorization to release medical information to the insurance company - Third-party payers will not process claims without access to the information to substantiate them - Telephone in queries regarding medical information o Very by caller has the original claim o Detailed information should be requested by caller on company letterhead o Very by who the caller says they are – call the insurance company o Never answer question from attorneys by phone unless authorization is on file with you not just the attorney and request the attorney to put questions in writing - Once the patient’s claim form is in hand, ask the caller to read a portion of the information to verify that the caller has the original. - If the caller is requesting a detailed explanation, ask that the questions be submitted in writing on company letterhead. - Ask the caller for the insurance company’s telephone number. Call the person back through the company switchboard to verify identity. - Never answer questions from attorneys until the authorization for release of information is in hand, even if the attorney claims to have it. The best practice is to correspond by mail with attorneys regarding insurance reimbursement cases. - Fraud o Criminal misrepresentation for the purpose of financial gain. (e.g. change the date of an injury, treatment, a assessment, or fail to record payments from the insurance company on a patient’s bill, reimbursement) |
| Legal Concerns and Insurance Issues |