Guide for Workers Comp Adjusters: When to Use an IME?

Quality IMEs can provide several benefits to the injured patient. Find out how to make a claimant more comfortable with the idea of an IME and the importance of choosing a reliable physician.

 Currently, there are over 2.8 million nonfatal accidents and injuries in the workplace every year.

When to Use an IME?

Work injuries happen regularly. Florida alone has 706K workers in the construction industry as of 2021. So how do you determine when an IME is needed?

These are scenarios that warrant an IME:

1. An unusually long recovery time
2. A premature or unrelated surgery request or questionable mechanism
3. When you see excessive treatment with no signs of improvement
   a. Example; claimants with over a hundred physical therapy visits or even multiple steroid injections with no relief or benefit.
4. When a claimant sustains a relatively minor injury but still receives a high disability rating from their doctor.

The reality is that IME’s are a way of confirming the honesty of physicians, claimants, and attorneys. Fraud is being committed in every corner of this industry and eventually will worsen things for all of us.

How Can an IME Help?

Certain injuries are harder to diagnose and therefore confirm if they are legitimate. Soft injuries are aches and pains, and largely used by fraudsters when placing a phony insurance claim

Independent medical evaluations also account for someone’s prior medical history, to confirm diagnoses aren’t based on pre-existing conditions.

An unbiased examination by a qualified doctor provides clarity for both parties. If the claim is legitimate, then the insured gains a second opinion from a physician and the insurance company the professional opinion they need.

FAQ’s

Claims examiners face unique challenges that delay their claims resolution time and budget. Lets discuss how an IME can provide you with clear insight into some common concerns:

• Did the work environment cause the injury, condition, or other symptoms – or instead was it caused by a separate, unrelated issue?
• Is the treatment plan appropriate for the diagnosis, mechanism of injury, and accepted body parts?
• What is the maximum medical improvement rate? Is there partial or permanent disability?
• When will the claimant return to work whether that is on full, light, or sedentary duty?

Who can perform an IME?

TPAs and insurance companies are free to choose their own IME physicians, though many opt for a vendor to help in this process.
Main factors involved in choosing an IME physician:

Jurisdiction: it’s important to confirm your doctor has a stellar background and is approved to practice medicine in your state.

Medical specialty: you want to select a specialty doctor that understands your case. For example, you wouldn’t send a neck injury to an ophthalmologist.

Finding a Quality IME physician

Doctors who perform IMEs are treated to witness standards and must show their validity.

Claims staff – adjusters and claims examiners are at the forefront of these claims and set the tone for quality and fairness.
IME vendor – your IME vendor must truly understand your case and pay attention to what doctor you need and why you are requesting this service. Are they in this purely for the money or to aid in your cost containment strategy?

You probably think using a known provider is the most efficient option for this service, but it’s not. You want to use a credible, trustworthy doctor but if the judge sees every one of your claims is handled by the same physician, that will raise a flag.

The most critical factor in an IME selection is the objectivity of the physician.

Not only will this deter from the court’s opinion about your credibility but will also appear as a lack of good faith given to the claimant. The opposing side will paint this behavior as biased and attempt to discredit your IME results. That’s why using a third-party IME vendor who has no attachment to any one provider shows credibility on your behalf. This way there is no bias to the outcome, just an interest in finding the most qualified medical expert to review the case and provide an objective opinion

IME Doctor Selection

Researching if your IME physician is board-certified and has no sanctions against them can be laborious. However not researching this can hamper the viability of an IME in a court setting. Let’s say your IME doctor has an ongoing lawsuit in Washington state, but he is practicing in Florida with no issues. Those previous legal issues will come up in court and discredit your case. Nip this in the bud by using an IME vendor with experience in physician vetting, ensuring quality and peace of mind.

A good IME vendor will also have established relationships with physicians and will iron out all pre-exam elements necessary in advance for your doctor. Once the report is done they will review it to make sure it meets your claims management needs. Random IME selection can lead to random results.

Cover letters

These are the letters being sent to your IME physician that outline the issues to be addressed in the IME report. Writing an effective cover letter is often the only opportunity you have to draw the physician’s attention to the facts at hand.

Remember: IME results are only as good as the communication provided about your request. If physicians are unsure of your expectations, they may provide irrelevant information that doesn’t help with claim resolution. In addition, they may not provide opinions on the topics most pressing for your claim! So you must specifically ask about those topics.

Example of vague, general IME question:

Do you have any further medical treatment recommendations?  If so, please outline the specific treatment and duration of the treatment plan.

Example of detailed, specific IME question:

Is the spinal surgery for L4 and L5 proposed by Dr. Johnson on 12/1/23 reasonable, necessary, and causally related to this claim?  If yes, please indicate why it would benefit and how it relates to the injury.

Early Detection is Key

While many work injury claims follow a normal flow of treatment and recovery, disruptions call for an Independent Medical Examination (IME). IMEs benefit the patient, their employer, and the insurance company. Using IMEs helps injured individuals recover and return to work sooner, benefiting everyone involved and accelerating claim resolutions.