Chapter 3 - Legal Concerns and Insurance Issues

Question 1

Liability

Answer 1

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

Question 2

Malpractice

Answer 2

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

Question 3

Liability can be based on…

Answer 3

negligent pt care
failure to obtain informed consent
intentional conduct
breach of a contract
use/transfer of a defective product
abnormally dangerous tx

Question 4

negligence

Answer 4

failure to act as a reasonably prudent athletic trainer would act under the circumstances

Question 5

standard of reasonable care

Answer 5

assumes that an individual is neither exceptionally skillful nor extraordinarily cautious, but is a person of reasonable and ordinary prudence

Question 6

tort

Answer 6

legal wrong, other than a breach of contract, for with a remedy will be provided, usually in the form of monetary damages

Question 7

nonfeasance

Answer 7

act of omission - when an individual fails to perform a legal duty

Question 8

malfeasance

Answer 8

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

Question 9

misfeasance

Answer 9

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

Question 10

sovreign immunity

Answer 10

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

Question 11

good samaritin law

Answer 11

provides limited protection against legal liability to any person who voluntarily chooses to provide first aid

can’t be used by AT in the work setting

Question 12

how does a defendant prove negligence?

Answer 12

1. ) conduct - AT must have done something to cause harm
2. ) duty - duty to pateint must exist
3. ) Breach of duty - breached duty owed to patient
4. ) Causation - what the AT did MUST have been directly the cause of the harm
5. ) Damage or harm - must have incurred

Question 13

Statue of limitations

Answer 13

sets a specific length of time that individuals may sue for damages from negligence

plaintiffs have 1-3 years to apply for negligence

Question 14

assumption of risk

Answer 14

injured plaintiff understood the risk of an activity and freely chose to undertake the activity regardless of the hazards associated with it

Question 15

comparative negligence

Answer 15

the degree to with the plaintiff contributed to the harm caused by a defendant

Question 16

product liability

Answer 16

liability of any or all parties along the chain of manufacture of any product for damage caused by that product

Question 17

medical insurance

Answer 17

contract between policyholder and insurance company to reimburse a % of the cost of the bill

Question 18

health insurance

Answer 18

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

Question 19

policy

Answer 19

contract between an insurance company and an individual or org

Question 20

riders

Answer 20

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

Question 21

premium

Answer 21

invoiced cost of an insurance policy

Question 22

deductible

Answer 22

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

Question 23

copayment

Answer 23

capped contribution defined in the policy and paid by an insured person each time a medical service is accessed.

Question 24

professional liability insurance (3 types)

Answer 24

only covers in civil cases

1. ) claims made - only covers claims made during calendar year
2. ) tail coverage: covers outside of policy year
3. ) occurrence policy: covers any incident during the policy year (and situations not work related)

Question 25

catastrophic insurance

Answer 25

designed to provide lifelong medical, rehab, and disability benefits for the victims of a devastating injury

• takes effect after first $25,000 in damages
• based on # of sports and hazardous sports offered

Question 26

UCR

Answer 26

usual (fee for service charged, customary (fee for geographically area), reasonable fee (lower of either U or C)

Question 27

Self-Insurance

Answer 27

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 for student/athletes
-

Question 28

Primary Coverage

Answer 28

health/medical/accident insurance that begins to pay for covered expenses immediately after a deductible has been paid

• athlete’s personal insurance should not cover medical bills
• expensive, most don’t use this

Question 29

Secondary Coverage

Answer 29

insurance that begins to pay once all other sources of insurance coverage have been exhausted

Question 30

medical practice act

Answer 30

state law regulating the practice of medicine, usually by specifying who many practice and under what circumstances

Question 31

Licensure

Answer 31

form of state credentialing, established by statute and intended to protect the public,
regulates the practice of AT trade by specifying who may practice and what duties they may perform

• unlicensed cannot call themselves AT
• unlicensed cannot practice

Question 32

certification

Answer 32

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

NATABOC - Role Delineation Study

Question 33

exemption

Answer 33

a legislative mechanism used to release members of one profession from the liability of violating another profession’s practice act

Question 34

Third-party reimbursement

Answer 34

the process by which medical vendors receive reimbursement from insurance companies for services provided to policyholders

Question 35

Fee-for-service/indemnity plans

Answer 35

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

Question 36

HMO

Answer 36

health maintenance org

requires policyholders to use only those medical vendors approved by the company
must be referred by primary physician first

Question 37

PPO

Answer 37

preferred provider orgs

provides financial incentives to encourage policyholders to use medical vendors approved by the company
-greater choice, smaller deductible, higher premium

Question 38

Medicare

Answer 38

government sponsored program for elderly, disabled

Question 39

Medicaid

Answer 39

government sponsored program for needy, low income

Question 40

ICD-9-CM

Answer 40

International Classification of Diseases

coding system applied to illnesses, injuries, and other medical conditions to standardize the language associated with 3rd party reimbursement

Question 41

CPT

Answer 41

current procedural terminology

coding for specific medical procedures to standardize the language associated with 3rd-party reimbursement

Question 42

EOB

Answer 42

• explanation of benefits
• do not submit claims to 2ndary insurance before receiving 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

Question 43

how to establish negligence

Answer 43

1. ) duty of care exists between 2 people
2. ) conduct of defendant fell short
3. ) defendant caused the injury
4. ) damages resulted