Chapter 3: Legal Concerns and Insurance Flashcards
What is liability?
Being legally responsible for the harm one causes another person.
What is negligence?
When an ATC 1) does something a reasonable person wouldn’t do (commission), 2)fails to do something a reasonably prudent person would do (omission)….DUTY to exercise care, BREACHED the duty by failing to provide reasonable care, HARM done to a person because of the care given/not given.
What is duty of care?
Part of an official job description
What are torts?
Legal wrongs committed against a person or a person’s property.
What is nonfeasance/omission?
When an individual fails to perform a legal duty….act of omission.
What is malfeasance/comission?
When an individual commits an act that is not legally his to perform…act of commission.
What is misfeasance?
When an individual improperly does something he or she has the legal right to do.
What is sovereign immunity?
States that neither the government nor any individual employed by the government can be held liable for negligence.
What is the Good Samaritan Law?
Provides limited protection against legal liability to any person who voluntarily chooses to provide first aid. As long as the first-aid provider does not overstep the limits of his professional training and exercises reasonable care.
What is a statute of limitation?
It sets a specific length of time that individuals may sue for damages from negligence, and varies from state to state. Generally, 3 years.
What is assumption of risk?
When the individual though express of implied agreement assumes that some risk or danger will be involved in the particular undertaking. The ATC is responsible for the athlete signing this document.
What are some steps an ATC can take to reduce the risk of litigation?
1) work to establish good personal relationships with athletes, parents, clients, & coworkers.
2) Establish specific policies and guidelines for ATR operation and maintain adequate supervision of the facilities and those inside it.
3) Purchase professional liability insurance.
4) Know the scope of practice and personal limitations
5) Do not let injured players participate without physician consent.
6) Keep accurate documentation
What is a copayment?
A provision in an insurance policy requiring the policyholder to pay a specified percentage of each medical claim.
What are exclusions?
Specified medical services, disorders, treatments, diseases, and durable medical equipment that are listed as uncovered or not reimbursable in an insurance policy.
Who is the gatekeeper?
The PCP that oversees the medical care of a patient and initiates specialty and ancillary services.
What is a premium?
A periodic payment made to an insurance company by an individual policy.
What is a rider?
Supplemental benefits
What does UCR stand for? What does it mean?
Usual, Customary, & Reasonable. It is a charge that represents the max amount an insurance company will pay for given services based on geographical averages.
What is accident insurance?
Insurance that covers accidents on school grounds while the student is in attendance, or workplace accidents. Protects against financial loss from medical bills
What is Professional Liability Insurance?
Employers have this to protect against damages that may come from injuries on their property. It covers negligence and is concerned with whether supervision was reasonable and if unreasonable risk of harm was perceived by the injured person.
What is Catastrophic Insurance?
In case of catastrophic injuries that can affect society, family, individual, and institution. Provides medical, rehab, and transportation costs over $10k.
What is third-party reimbursement?
ATCs can bill as the third party for services given in settings such as hospital, clinics, physician’s offices and schools/universities.
What is an HMO?
Health Maintenance Organization. Preventative services, must go through PCP, generally pay 100% of costs if within network.
What is a PPO?
Preferred Provider Organization. Discount health care but limit where a person can go for treatment, must be on the approved list. Pay on a fee-for-service basis.
What is a POS?
Point of Service Plan. Combination of HMO/PPO. Based on HMO structure, but allows members to go outside HMO to get service.
What is an EPO?
Exclusive Provider Organization are a combination of HMO/PPO. They are restrictive in the # and type of providers they have and are more like an HMO. They will not pay if you use out of network.
What is Medicare?
It is a federal health insurance program for the aged and disabled. There are 4 parts. Part A is the hospital portion that is normally premium-free. Part B is the physician portion that has a monthly premium. Part C allows people to chose a health care plan. Part D is a federal program to subsidize the costs of Rx drugs for Medicare beneficiaries.
What is Medicaid?
A health insurance program for people with low income & limited resources. Funded by federal government and states. Benefits vary by state.
What is an Indemnity Plan?
It is the most traditional form for billing for health care. Fee-for-service plan that lets insured party seek medical care w/o restrictions. Provider charges patient or 3rd party.
What is Capitation?
A form of reimbursement used by managed care providers. Members make a standard payment each month regardless of how much service they receive that month.
What is an HCFA-1500 and UB-92?
a standard form when filing an insurance claim to submit for reimbursement. UB-92 is for BCBS.
What are the 2 types of billing codes that must be filed when submitting a claim?
The diagnostic code for procedural billing is called a International Classification of Diseases (ICD-9). It is a 5 digit code that specifies the injury. The procedural code is called the Current Procedure Terminology Code (CPT) and is used to identify specific medical procedures used to treat a patient.
What are deductibles?
The amount owed by the insured on a yearly basis before the insurance company will being to pay for services rendered
