By Michael Valasek, Vice President, IME Division, Genex Services
A certain amount of contention has come to surround the independent medical examination (IME) process. Oftentimes, both the insurer and claimant will obtain an IME to substantiate their respective opinions on a case. Rather than bringing about clarification, claims decisions can get bogged down and stalled.
Due to these issues, the workers’ compensation (WC) market has begun to demand an increased level of quality in the IME process to ensure the original intent of these exams – which is to obtain an impartial, expert medical opinion that will help determine the next step on the case. Currently, there are three stakeholders that play an integral role in producing a quality IME result:
1. Claims staff must observe a quality process when requesting an IME. Many times, claims professionals may not have all the information necessary to select the right physician. For example, they may not know if physicians have sanctions filed against them. If a vital component is left out in the provider selection process, the resulting IME report could lose credibility among state commissions, WC boards and court systems. A simple way to avoid this problem is to use a quality IME vendor that has fostered relationships with a broad pool of medical experts.
As soon as an opinion is in question on a case, a request should be made to clarify issues early on. Once a case has started down a certain path, it can be difficult to make a significant change in direction. For example, if an adjuster suspects treatment is deviating from normal guidelines, he or she should request an IME before the plan proceeds too far to be able to make a change.
To obtain a useful IME result, it’s imperative that claims staff state a clear objective and specific questions that should be addressed in the final report. This will allow IME physicians to understand what they’re being asked to evaluate. Claims staff should also provide all relevant background, including a comprehensive medical record, diagnostic test results, job descriptions and claimant statements – all in advance of the exam. These records help the IME physicians to assess what’s going on. Is the condition improving? Is the patient fixed and stable?
2. The IME vendor must be a company that envisions and champions high standards for IME quality. In its IME process, objectivity is crucial. When employers or insurers request an IME directly from a physician, there’s a perception that the doctor is being recruited or paid to provide a specific medical opinion. Whereas, with a third-party IME vendor, impartiality is built into the process. The vendor identifies an expert qualified to evaluate the case, and since the IME vendor has no “skin in the game,” they have no bias in the outcome.
It’s the vendor that will ensure physicians are skilled at performing IMEs, don’t have sanctions filed against them and have active treating practices. The vendor will be familiar with the physicians’ areas of specialty, board certifications and expertise on body parts. In addition, the vendor will have in-depth knowledge of various jurisdictional requirements surrounding IMEs. Clinical coordinators will help organize medical records, highlight critical pieces of the file, and identify items physicians should review and consider in relation to the stated IME objective.
Obviously, the medical opinion is solely that of the examining physician, but a quality assurance process will ensure the final report expresses a clear medical opinion and addresses all questions that were posed.
3. IME physicians are critical to obtaining a quality result. If the two parties above – claims staff and IME vendors – carry out their respective roles, the claimant will be sent to the right physician who is qualified and skilled at performing these exams.
Although IME physicians are not facilitating treatment, a quality IME can still provide significant benefits to the injured workers. In many cases, the IME physicians may uncover medical issues previously overlooked, or they may connect the dots to figure out underlying issues or even solve a previously unexplained medical mystery. As a result, an IME can lead to the injured worker getting the treatment they need sooner, which is a significant benefit to their well-being.
Preparing for an IME usually begins a few days prior to the actual exam. The physician starts by reviewing the medical record. In some cases, these files include thousands of pages. IME physicians familiarize themselves with the claim and catch items that may be missing from the file. For example, if the physician is going to determine whether an injured employee is ready to return to work, a job description is needed, and the physician would still have time to request the missing information.
When an IME physician gives an opinion, it needs to be based on medical evidence and based within a reasonable degree of medical certainty, as there are legal ramifications that hold an IME to a high standard.
Raising the Bar on IME Quality
Claims staff, IME companies and physicians must be aware of the criteria leading to a quality IME result. Adhering to best practices must be established as a priority. Otherwise, complex claims have a greater risk of becoming prolonged, complicated and costly — and injured workers would be in jeopardy of not receiving the care they need to recover and return to work. The IME practices outlined in this paper enable organizations to join other leaders striving to consistently achieve quality IME results and to garner the benefits therein. Quality IME vendors are the conduit to getting injured workers matched to the best, most qualified IME physicians – resulting in an IME that drives informed decisions and moves claims closer to closure.
About Michael Valasek
Michael Valasek is vice president of the IME Division at Genex Services. He is the former president and CEO of Med-Eval, which was acquired by Genex Services in 2016. With over 17 years in workers’ compensation and healthcare, he provides organizations with access to quality medical legal opinions through enhanced service and workflow technologies.
About Genex Services, LLC
Genex Services is the trusted provider of managed care services enabling workers’ compensation payers and risk managers to transform their bottom lines while enhancing the lives of injured and disabled workers. Genex is a managed care leader with more than 2,900 employees and 41 service locations throughout North America. The company serves the top underwriters of workers’ compensation, automobile, disability insurance, third-party administrators and a significant number of Fortune 500 employers. In addition, Genex is the only company that delivers high-quality clinical services enhanced by intelligent systems and 360-degree data analysis. The company consistently drives superior results related to medical, wage loss, and productivity costs associated with claims in the workers’ compensation, disability, automobile, and health care systems.
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This is not a paid placement.