By Archie Anderson, Senior Vice President of Specialty Services, GENEX Services, LLC
For years the Independent Medical Exam (IME) has been a staple in the workers’ compensation claims resolution arsenal. We trot it out when claims linger, or when there’s a possible question regarding a treatment plan.
But there’s a lot more we could and should be doing with IME, especially in today’s complex workers’ compensation environment, where litigation and delays in return to work can be costly and have long-lasting ramifications.
While the IME has been around for years, how, when and where it is used has evolved over the years. At its essence, an IME is a “second opinion” for the diagnosis and treatment plan of an injured worker. The objectives of an IME lead to the successful resolution of a claim. They include:
- To validate what a treating provider or claimant says is the cause of an injury.
- To affirm diagnoses and treatment plans, including testing, necessity of surgery, physical therapy programs, etc.
- To provide information and insights necessary for reserving.
The scope of the IME can vary based on each state jurisdiction, so strategies for utilization will vary. Some workers’ compensation jurisdictions have strict guidelines on its timing and use. For example, Texas workers’ compensation rules allow a Required Medical Exam, which is the state’s version of an IME, every 180 days, but restrict what can be addressed in an exam. In some states, a claims adjuster may have only one opportunity to bring in an IME.
Costs can also vary. An orthopedic IME in New York City can be as low as $400, while one in Arizona can be as high as $2,000.
All these variations leave employers, claims administrators and carriers struggling to develop comprehensive, clear and consistent approaches to the IME. It also leads to mistakes in when, where and how an IME is applied. Common oversights include…
- Utilizing an IME late in the process; almost as a “hail Mary” type of strategy once a claim has started to spiral out of control.
- Using the wrong provider to conduct the IME, such as a non-practicing/retired MD or one with the wrong specialty – who may not have expertise in the claimant’s specific injury. Choosing the wrong MD for the IME is particularly risky if the claim should ever go into litigation processes as plaintiff attorneys will use lack of expertise as an argument against the IME conclusions and findings.
- Taking a perfunctory approach to the IME. Often an IME is brought in simply out of habit, with little thought given to how to use the exam to validate treatment plans or improve outcomes. Such an approach also wastes time and money and could extend the life of the claim.
IME Best Practices
While it’s important to be aware of common mistakes to avoid, there are steps to take to ensure optimal use of an IME. These include:
- Bring in the IME early, especially for complex claims such as those with significant claimant co-morbidities or where age, potential litigation or jurisdiction could be an issue. Using an IME early in a claim can address extent of injury issues and clearly define the accepted compensable injury. This can be instrumental in shaping the eventual outcome of a claim by excluding pre-existing injuries and underlying conditions which can “creep’ into a claim if left unchecked.
- Take a look at the providers and the organization behind your IME processes. Make sure they are experienced, qualified and offer a range of local providers that have “specialty-to-specialty” expertise in diagnosis and treatment for the injury in question.
- Learn from your mistakes. If there have been situations where you were not satisfied with the results from your IME, dig deeper and find out why. Was the IME provider not qualified to address a specific injury or body part/condition? Was he/she brought in too late to make a difference? Ensure your IME provider has the ability to collect and analyze data so you can learn what works best.
- Be specific. Often questions posed in an IME are too general – what type of surgery is best – how long should treatment last, etc. If you have an IME provider with experience in a particular injury – e.g., frozen shoulder or carpal tunnel – ask for specific insights and recommendations. For example, what factors could influence RTW or does the age of a claimant affect treatment plans? What specific testing and/or equipment/medical technology has been utilized to determine diagnosis, assessments, etc; and are they up-to-date?
Another important benefit of an IME is its value as a tool to help in accurately setting claim reserves. Knowing how long treatment will take and what it will cost can help to better set reserves. Setting reserves at the right amount is a core strategy for the claims administration process as it helps value and mitigate financial exposure and can help improve an organization’s bottom line.
The IME is an important step in the claims resolution process and in an overall RTW strategy. Develop guidelines and use the IME wisely and it can become a key component of an effective workers’ comp claims resolution process.
About Archie Anderson
Archie Anderson, Senior Vice President of Specialty Services at GENEX Services, LLC, has more than 27 years of leadership experience in the workers’ compensation, employee benefits and risk management industries. His current responsibilities include the IME and the Social Security/Managed Disability business units of GENEX, and the Optis® data integration and cloud software business, which is an independent operating subsidiary of GENEX. Archie is a graduate of Northwestern State University of Louisiana, where he earned a B.S. in Business Administration and an M.A. in Higher Education Administration and Counseling.
About GENEX Services, LLC
GENEX Services is the trusted provider of managed care services that enables workers’ compensation payors and risk managers to transform their bottom lines. GENEX is the most experienced managed care provider in the industry, with more than 2,500 employees and 47 service locations throughout North America. The company serves 381 of the top Fortune 500 companies in the U.S. today. In addition, GENEX is the only company that delivers high quality clinical services enhanced by intelligent systems and 360-degree data analysis to consistently drive superior results related to medical, wage loss, and productivity costs associated with claims in the workers’ compensation, disability, automobile, and health care systems. Optis is an independent operating subsidiary of Genex Services, LLC. Optis provides data management and software services for human resources, employee benefits and risk management. For more information visit www.optis.com and www.genexservices.com.
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This is not a paid placement.