Chapter 3: Legal Concerns and Insurance

Question 1

What is liability?

Answer 1

Being legally responsible for the harm one causes another person.

Question 2

What is negligence?

Answer 2

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.

Question 3

What is duty of care?

Answer 3

Part of an official job description

Question 4

What are torts?

Answer 4

Legal wrongs committed against a person or a person’s property.

Question 5

What is nonfeasance/omission?

Answer 5

When an individual fails to perform a legal duty….act of omission.

Question 6

What is malfeasance/comission?

Answer 6

When an individual commits an act that is not legally his to perform…act of commission.

Question 7

What is misfeasance?

Answer 7

When an individual improperly does something he or she has the legal right to do.

Question 8

What is sovereign immunity?

Answer 8

States that neither the government nor any individual employed by the government can be held liable for negligence.

Question 9

What is the Good Samaritan Law?

Answer 9

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.

Question 10

What is a statute of limitation?

Answer 10

It sets a specific length of time that individuals may sue for damages from negligence, and varies from state to state. Generally, 3 years.

Question 11

What is assumption of risk?

Answer 11

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.

Question 12

What are some steps an ATC can take to reduce the risk of litigation?

Answer 12

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

Question 13

What is a copayment?

Answer 13

A provision in an insurance policy requiring the policyholder to pay a specified percentage of each medical claim.

Question 14

What are exclusions?

Answer 14

Specified medical services, disorders, treatments, diseases, and durable medical equipment that are listed as uncovered or not reimbursable in an insurance policy.

Question 15

Who is the gatekeeper?

Answer 15

The PCP that oversees the medical care of a patient and initiates specialty and ancillary services.

Question 16

What is a premium?

Answer 16

A periodic payment made to an insurance company by an individual policy.

Question 17

What is a rider?

Answer 17

Supplemental benefits

Question 18

What does UCR stand for? What does it mean?

Answer 18

Usual, Customary, & Reasonable. It is a charge that represents the max amount an insurance company will pay for given services based on geographical averages.

Question 19

What is accident insurance?

Answer 19

Insurance that covers accidents on school grounds while the student is in attendance, or workplace accidents. Protects against financial loss from medical bills

Question 20

What is Professional Liability Insurance?

Answer 20

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.

Question 21

What is Catastrophic Insurance?

Answer 21

In case of catastrophic injuries that can affect society, family, individual, and institution. Provides medical, rehab, and transportation costs over $10k.

Question 22

What is third-party reimbursement?

Answer 22

ATCs can bill as the third party for services given in settings such as hospital, clinics, physician’s offices and schools/universities.

Question 23

What is an HMO?

Answer 23

Health Maintenance Organization. Preventative services, must go through PCP, generally pay 100% of costs if within network.

Question 24

What is a PPO?

Answer 24

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.

Question 25

What is a POS?

Answer 25

Point of Service Plan. Combination of HMO/PPO. Based on HMO structure, but allows members to go outside HMO to get service.

Question 26

What is an EPO?

Answer 26

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.

Question 27

What is Medicare?

Answer 27

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.

Question 28

What is Medicaid?

Answer 28

A health insurance program for people with low income & limited resources. Funded by federal government and states. Benefits vary by state.

Question 29

What is an Indemnity Plan?

Answer 29

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.

Question 30

What is Capitation?

Answer 30

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.

Question 31

What is an HCFA-1500 and UB-92?

Answer 31

a standard form when filing an insurance claim to submit for reimbursement. UB-92 is for BCBS.

Question 32

What are the 2 types of billing codes that must be filed when submitting a claim?

Answer 32

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.

Question 33

What are deductibles?

Answer 33

The amount owed by the insured on a yearly basis before the insurance company will being to pay for services rendered