Chapter 3 - Legal Concerns and Insurance Issues

Transcription

1 Chapter 3 - Legal Concerns and Insurance Issues LEGAL TERMINOLOGY 1. Liability - being legally responsible for the harm one causes another person 2. Negligence failure to use ordinary or reasonable care THREE NECESSITIES TO ESTABLISH NEGLIGENCE 1. Duty of care existed between the injured and the person responsible for injury 2. Defendant s actions fall short of duty of care 3. Damages resulted from the defendant s actions LEGAL TERMINOLOGY (cont.) 1. Standard of reasonable care individual is neither exceptionally skillful or cautious, but brings reasonable common to a situation and will exercise due care 2. AT must act according to the standard of care of an individual with similar education background and training. Torts legal wrongs committed against the person or property of another Nonfeasance (act of omission) individual fails to perform a legal duty Malfeasance (act of commission) individual commits an act that is not legally theirs to perform Misfeasance individual improperly does something that he or she has the legal right to do 3. Tort of negligence is usually what ATs are sued for. AT does something that a reasonably prudent person OR AT fails to do something that a reasonably prudent person would do under the circumstances 4. Once an AT assumes the duty to care for a patient the AT has made an obligation to ensure appropriate care is given 5. No one is obligated to care for an injured person outside their scope of practice LEGAL TERMINOLOGY (cont.) 1. Good Samaritan Law provides limited protection against legal liability to anyone who voluntarily chooses to provide first aid Varies from state to state Limited protection as long as the first aid provider does not overstep the limits of his or her professional training that would be considered reasonable care in the situation in the situation Professional? gifts/money effect on Good Samaritan If you accept any type of gift/money/food/anything, the Good Samaritan Law is voided.

2 2. Statute of limitations sets a specific length of time that individuals may sue from damages from negligence Varies from state to state Some states allow a minor up to 3 years after turning 18 to sue for negligence 3. Assumption of Risk the individual, either implied or expressed, assumes that some risk or danger will be involved in the particular undertaking This in no way excuses those in charge from exercising reasonable care and prudence or from taking precautionary steps against accident-provoking circumstances 4. Product liability refers to the liability of a product manufacturer, wholesaler, and retail storeowner Products containing inherent defects that cause harm are subject to product liability SHOT GUN OR DEEP POCKET APPROACH 1. A victim s lawsuit will include all parties involved AT Employer Physician Administrator(s) Company or school district Product manufacturer (if a product is involved) INSURANCE CONSIDERATIONS 1. Health care focuses on managed care. Costs of a health care provider s medical care are closely monitored and scrutinized by insurance carriers. Often pre-approval is needed before care can be given. 2. Medical insurance is a contract between an insurance company and a policy holder in which the insurance company agrees to reimburse a portion of the total medical bill after some deductible has been paid by the policyholder. TYPES OF INSURANCE ATs SHOULD BE CONCERNED WITH 1. General health 2. Accident 3. Professional liability 4. Catastrophic TYPES OF INSURANCE 1. General health Insurance covers illness, hospitalization and emergency care Primary coverage paid for by the institution (institution pays high premiums)

3 Secondary coverage pays remaining medical bills once the personal insurance company has made its payment 2. Accident Insurance covers accidents that occur on school grounds while student is in attendance or at workplace when employee is in attendance Often low cost Often limited in coverage and payouts (I.e. students may not be covered when playing collision sports, fights) 3. Professional liability insurance that covers claims of negligence on the part of the individual (malpractice insurance) Premiums are often prohibitive Understand limits Typically covers negligence in a civil case, but not in a criminal case The goal of the prosecution is to get as much compensation for the individual as possible. 4. Catastrophic Insurance - provides coverage for a lifetime of extensive medical care and rehabilitation for permanent disabilities that occur as a result of an accident Bought by the institution or organization Benefits generally begin when expenses reach $25,000 and extend for a lifetime Insurance issues are often part of the job description of ATs. THIRD-PARTY REIMBURSEMENT (HOW OUR INSURANCE WORKS) 1. Primary mechanism of payment for medical services in the United States. The policyholder s insurance reimburses health-care professionals for services rendered. Costs for services rendered are often standardized (CPT codes) 2. ATs have always been legally able to bill for services rendered. 3. In the 90s and early 2000s, third-party reimbursement for ATs increased for those working in hospitals, clinics, physician s offices and colleges and universities. 4. Third-party payers generally will only reimburse licensed health care professionals. THIRD- PARTY REIMBURSEMENT (cont.) 1996 NATA initiated the Athletic Training Outcomes Assessment project. Provided data that measures the results of interventions that involve AT procedures. 3 year outcomes study Showed our value as AT s AT OUTCOMES STUDY (Could be a short answer question) 1. Functional outcomes 2. Patient perception of function and overall satisfaction with services received 3. Physical, emotional, and social well-being of patients 4. Cost effectiveness relative to time lost from activity due to injury

4 5. Number of treatments needed Study showed athletic training services to be more cost effective with good results and good patient feedback. FILING AN INSURANCE CLAIM 1. Standard forms HFCA-1500/HFCA-1450 UB-92 (Blue Cross and Blue Shield) 2. Diagnostic code specifies the condition or injury being treated 3. Procedural code (CPT) specifies medical procedure performed (CPT s are procedural code)

5 Chapter 9 - Mechanisms and Characteristics of Musculoskeletal and Nerve Trauma TERMINOLOGY Tissue properties Load: external force acting on tissues which causes internal reactions Stiffness: ability of tissue to resist a load Stress: the internal resistance to an external load Deformation: abnormal change in shape usually due to an external load Elasticity: properties which allow a tissue to return to normal following deformation Yield point: tissue reaches a deformation state in which it no longer has elasticity Plastic: permanent tissue damage after load is removed Creep: deformation that occurs over time Mechanical failure: tissue break-down resulting from exceeding the ability to withstand stress Clinical Application Explain how an external stress can lead to an ankle sprain in a patient who steps off a curb wrong. (Using load, deformity, elasticity, and yield point) Biomechanical answer: An external load causes internal strain and deformity to the ligament. When the ligament reaches the extreme of its elasticity, the yield point is exceeded and a sprain. TISSUE LOADING 5 types of tissue loading 1. Tension: force that pulls or stretches tissue (muscle strains, ligament sprains) 2. Compression: external loads applied toward one another on opposite surfaces in opposite directions (arthritic changes) 3. Shearing: equal, but not directly opposite loads are applied to opposing surfaces forcing them to move in parallel directions (blisters, abrasions) 4. Bending: 4pt load 2 force pairs act on opposite ends 3pt load 3 forces cause bending (1 on each end, one in the middle) Axial loading force applied to an already bowed structure 5. Torsion: Twisting in opposite directions from the opposite ends of a structure causing a shear stress TRAUMATIC VS. OVERUSE INJURIES Acute: Fresh injury, usually traumatic in nature Chronic: Injuries that occur over time, an acute injury that does not heal properly becomes acute. Often result from overuse. MUSCULOTENDINOUS UNIT INJURIES