Chapter 3 - Legal Concerns and Insurance Issues Flashcards Preview

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Flashcards in Chapter 3 - Legal Concerns and Insurance Issues Deck (43)
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1
Q

Liability

A

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

2
Q

Malpractice

A

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

3
Q

Liability can be based on…

A
negligent pt care
failure to obtain informed consent
intentional conduct
breach of a contract
use/transfer of a defective product
abnormally dangerous tx
4
Q

negligence

A

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

5
Q

standard of reasonable care

A

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

6
Q

tort

A

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

7
Q

nonfeasance

A

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

8
Q

malfeasance

A

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

9
Q

misfeasance

A

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

10
Q

sovreign immunity

A

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

11
Q

good samaritin law

A

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

12
Q

how does a defendant prove negligence?

A
  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
13
Q

Statue of limitations

A

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

plaintiffs have 1-3 years to apply for negligence

14
Q

assumption of risk

A

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

15
Q

comparative negligence

A

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

16
Q

product liability

A

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

17
Q

medical insurance

A

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

18
Q

health insurance

A

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

19
Q

policy

A

contract between an insurance company and an individual or org

20
Q

riders

A

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

21
Q

premium

A

invoiced cost of an insurance policy

22
Q

deductible

A

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

23
Q

copayment

A

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

24
Q

professional liability insurance (3 types)

A

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)
25
Q

catastrophic insurance

A

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
26
Q

UCR

A

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

27
Q

Self-Insurance

A

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
-

28
Q

Primary Coverage

A

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
29
Q

Secondary Coverage

A

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

30
Q

medical practice act

A

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

31
Q

Licensure

A

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
32
Q

certification

A

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

33
Q

exemption

A

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

34
Q

Third-party reimbursement

A

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

35
Q

Fee-for-service/indemnity plans

A

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

36
Q

HMO

A

health maintenance org

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

37
Q

PPO

A

preferred provider orgs

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

38
Q

Medicare

A

government sponsored program for elderly, disabled

39
Q

Medicaid

A

government sponsored program for needy, low income

40
Q

ICD-9-CM

A

International Classification of Diseases

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

41
Q

CPT

A

current procedural terminology

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

42
Q

EOB

A
  • 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
43
Q

how to establish negligence

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

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