Top 5 Reasons to Request an Independent Medical Examination

Whether it is workers’ comp, liability, physical injury, or property, verifying the medical diagnosis of your claimant can be a game changer. Having an impartial third party evaluate a diagnosis holds weight in front of a judge. Keep reading to find out if your case could benefit from an IME.

What is an Independent Medical Examination?

Read our “What is an IME? (And Why They’re Needed)” article if you want an in-depth explanation but here is a recap: The IME is your star witness. It brings an unbiased medical expert to objectively assess the patient’s condition. They review the claimant’s medical history, order labs, and will collect any information the patient provides about their injury.

According to the BLS, in 2019 the most common type of workplace injuries were sprains, strains and tears. There were 327,650 of these types of work-related injuries in 2019.

Occupational Safety and Health Administration (OSHA) has done more for workplace safety than any other department. Since the 1970s, when OSHA was founded, workplace fatalities have gone down more than 60%. However, this agency has a limited budget and even more limited personnel.

• OSHA maintains 1,850 combined federal and state inspectors, who collectively are responsible for the safety of 130 million American workers.
• They have 10 regional, and 85 local offices. A small number considering the over 8 million worksites across the country.
• This means that there is about 1 inspector for every 70,000 workers. In 2019, OSHA conducted 33,393 federal and 42,063 state inspections.
• It is not OSHA’s fault and it is not your fault but the losses are immeasurable.

There is simply a lack of funding in this segment and it affects all of us, especially when fraudulent claims fall through the cracks and ultimately raise insurance costs for everyone.

Unfortunately, you can’t stop all workplace injuries. Neither can an IME, people are human and accidents happen. What an IME can do is help you verify the real versus questionable cases for you.

Top 5 Reasons to Request an Independent Medical Examination

1) Lower costs by 15%

The lowest average workers’ compensation settlement is caused by occupational disease or a cumulative injury and results in a cost of $16,696 on average. Meanwhile the most costly is due to amputation which results in $118,837 on average. An IME might not be cheap, but it would only cost you 15 percent of an average, lower-end WC settlement.

2) Uncover the cause

If the cause of a claimant’s injury seems unclear, an IME physician can be instrumental in determining the source of the injuries.

3) Bring in an expert third-party

An independent medical examination in a workers’ compensation case can provide you with a valuable third-party opinion on medical treatment and prognosis.

For example:

Imagine a claimant continues cashing in for the same incident. He knows where the rock is but continues to fall into it. OSHA hasn’t had the time or personnel to verify this case and it’s slipped through the cracks once again. To break free from this pattern you decide to request an IME and determine if the patient’s injuries persist or if the claim is false.

4) Solve your claim with indisputable evidence

Bringing in a neutral third party levels the playing field. The IME doctor can help resolve disputes between the claimant’s health providers and the insurance company. An Independent medical examiner will break down the patient’s condition and provide their opinion during litigation if needed.

5) Eliminate fraud concerns

IME physicians have a career’s worth of knowledge about the human body and its response to injury. They can decipher what symptoms don’t align with the incident or if there is something suspicious about the case and subsequent injuries.

Use Case

A case manager was getting ready to pay off a 3-and-a-half million dollar life care plan but decided to quickly search for an “independent medical examiner near me.” With this much money involved, he figured it couldn’t hurt to assign an IME and cross off any doubt.

The Case

The case involved a veterinarian technician who sprained her back while carrying a sick dog. She claimed the dog was skittish, and heavy, and kept moving around resulting in her spraining her back while carrying it. Days later she was experiencing horrible lower back and neck pain, after a visit to the emergency room due to the persistent pain, the doctor said she was going to need spinal surgery for her 2 herniated discs.

The Symptoms

They went on to operate on her most symptomatic one, L5-S1 however her pain got worse and after an MRI they figured out she had an epidural bleed, an epidural hematoma, and developed paraparesis. A final surgery was done to evacuate the clot and seal up the bleeding. After 2 months at a rehab hospital, she was still in a motorized wheelchair, with her mother and daughter being paid 125$ per day to do intermittent catheterization 4 times a day. The patient shows up to her IME appointment with a Foley catheter and in a wheelchair. The IME physician observes there is no atrophy, no pathological reflexes, and no spasticity, yet she says she feels nothing below her waist.

The False Claim

The doctor conducts a foot exam to test for the Babinski Reflex and observes she has calluses and black marks on her heels, common for people who walk barefoot. This patient’s symptoms raise a red flag for the doctor who goes on to present all of his findings to the case manager and warns there might be more than meets the eye. Long story short, this case goes on to require two rounds of surveillance which ultimately found the claimant guilty of insurance fraud. This is an example of extreme malingering and symptom magnifier. In cases like this where there is so much money involved, people are willing to go the extra mile and if you aren’t careful you might fall victim to their false claims.

The Need for IME’s

Ultimately, you have the right to make sure you are not being defrauded. This process can move quickly if both parties are moving in good faith but that’s not always the case, if not, investigations and IMEs would not exist. Workers’ compensation settlements can be tempting and have caused countless people to commit fraud. It’s unfortunate, but employees see work comp payouts as retirement funds or lifestyle upkeep money. Requesting an IME can be the nail in the coffin for a case that needs to determine causation, real evidence for court litigations, or aims for cost containment and preventing fraud.

Contact one of our in-house Independent Medical Examiners to assist with your case. Assigning your case to a physician and coordinating cooperation is something you can outsource. Ethos is here to make it easier and faster for you to settle or deny claims.