By Richard Leonardo, Senior VP of IME and Specialty Services, Genex Services
When you’re in the market for a new home, a real estate agent might show you a property that has “good bones.” Generally speaking, this means the house has a solid structure and agreeable layout. More importantly, it’s well suited to your purpose – whether it’s accommodating a growing family or downsizing for retirement.
By that same token – with over 20 years of experience in the workers’ compensation industry – I’ve developed a keen eye for spotting “good bones” in the provision of quality independent medical examinations (IMEs). When our team of experienced professionals talk about coordinating quality IMEs, we mean being able to arrange IMEs with the right physicians, qualified to provide medical opinions on questions regarding treatment, return to work, and other issues specific to the claim at hand.
Many workers’ comp programs won’t consider the framework in which their stakeholders request IMEs, until they notice the consequences of a poor process – such as IME reports that don’t contain the medical expertise needed, expensive yet avoidable addendums and, even more harmful, the integrity of an IME being called into question in legal proceedings.
A critical element that gives an IME the right structure and framework is the cover letter. In this article, we’ll discuss why this is such a vital piece of communication and provide six ways to develop a cover letter that minimizes delays and provides the best-possible IME result.
1. Understand the value and importance of a quality IME cover letter.
Anecdotally speaking, according to my experienced staff, only about 60% of IME cover letters are submitted with all the right stuff – meaning as much as 40% lack the structure and framework to bring about the medical expertise needed on a case. This can result in significant waste from costly, avoidable addendums if the cover letter is not done right the first time and delays in the overall claims-handling, treatment, and return-to-work process.
In an ideal situation, an IME should be completed with one exam and report to avoid confusion. Addendums are intended to be used when new information – such as a new test result – becomes available after an initial IME is performed. However, a client may be forced to use an addendum, if something wasn’t clearly outlined in the initial IME cover letter. Another undesirable outcome is that unnecessary addendums bring the integrity of the IME into question, as it can give the impression that a provider is piecing together an opinion.
Adjusters, case managers, and attorneys are common parties requesting IMEs. These requesters often won’t notice something has gone awry until they receive the resulting IME report. At that point, they may notice that it lacks the physician’s medical opinion on a vital component of the claim. When our department investigates, it’s often the case that this issue wasn’t clearly outlined in the initial cover letter.
Essentially, the cover letter provides the framework for the IME physician to approach the exam. However, not all requesters know how to develop an effective cover letter. Today, many experienced adjusters have retired or, due to COVID, they’re working remotely. As a result, newly hired or junior staff may be without proper guidance.
Because of these challenges, our team designed a course on how to develop effective IME cover letters. This training outlines comprehensive guidance and best practices, which we summarize in this article. When followed, this approach can elicit the medical opinions needed on a case – the first time around.
2. Structure the cover letter around the purpose of the IME and ensure clear, concise communication with the IME physician.
IME physicians are extremely busy; they run active practices, many teach and serve as expert witnesses, in addition to performing IMEs. As a result, it’s important that a cover letter be clear and concise, minimizing the need for a physician to decipher what’s being asked.
In addition, the IME must be impartial, so a requesting party cannot be perceived as trying to influence the result. As such, requesters won’t have direct contact with the IME physician prior to the exam. Instead, it’s the cover letter that serves as the primary means of communication between the requester and IME physician.
The structure of a cover letter is key. We recommend an introduction that covers:
- The purpose for the IME. Explain why you’re requesting this IME at this point in time. Example: We’re referring this injured employee for an IME to evaluate his ability to return to work. Here, the purpose is short and to the point.
- Provide a brief history of the claim. This lets the physician know how the case got to where it is today and what you hope to accomplish. Many claims experience a winding, circuitous path – encompassing different body parts, physicians, treatments, and other factors. But the cover letter must stay focused around the purpose of the exam.
The overall tone of the letter must be factual and objective. Steer clear of stating opinions or emotions, as in the following examples:
The treating physician said the employee’s back pain had improved. I think he’s now complaining of a new ankle issue because he doesn’t want to return to work. (Avoid opinions.)
We’re trying to wean this injured employee off painkillers, but I’m upset and worried he’s selling his medication. (Avoid emotion and conjecture.)
3. Submit the cover letter and medical records at least 7-10 days prior to the IME in order to leverage an extra level of quality assurance.
The cover letter should be completed at least 7-10 days prior to the exam. This timing will enable the IME vendor to help perform a quality check on the cover letter and medical file before forwarding it to the physician.
For example, our department ensures that the purpose and questions are clearly stated and make sense. We double check that data outlined in the letter is aligned with information in the claim – such as the claimant’s name is correct; body parts are accurate; and the appropriate side of the body is referenced (right or left) – as well as review other areas where mistakes commonly occur.
Having the cover letter submitted within this timeframe significantly reduces errors and improves quality. We also recommend trying to send everything together – in one complete package – rather than piecemeal. This helps to ensure everything gets into the hands of the physician in aggregate and avoids documents getting lost or misplaced when sent separately.
4. Follow these other important guidelines.
During our training, we provided many helpful tips on how to write an effective cover letter. Perhaps the most important is “if something doesn’t get asked, it won’t get answered.” IME physicians often avoid elaborating beyond what is specifically asked of them. If there is something a requester really wants to know, it should be stated in the form of a question.
Other best practices include:
- Use a bulleted list for a series of questions. Oftentimes, a requester will list three or more questions in a row, all jammed together. Or, they’ll have one overarching question with a series of related questions. The physician might either answer the first or last question, inadvertently skipping those in the middle. This results in a delayed IME report because we need to go back and ask the doctor to offer an opinion on the missed questions. We recommend formatting a series of questions in a bulleted or subset list. This forces the physicians to see and respond to each and every one.
- Make sure documents are legible. The industry still relies on faxes as well as scanned documents. As such, use font, paper, and printing that supports legibility.
- Use only relevant questions. Many inexperienced requesters use predefined questions from a referral form. These are only provided as sample questions. Be sure the questions you use actually apply to your specific case. For example, refrain from asking the physician for an opinion on return to work, if the employee has already returned to full duty.
- No hidden messages. Requesters may know that there’s a “smoking gun” in the medical file, and they assume that the physician will see it. However, medical files can be quite thick, so the record could be overlooked. When the doctor doesn’t comment on that record, the requester will say, “Didn’t the doctor review this piece of information?” This leads to an unnecessary addendum, as our team has to go back and ask the physician to review that record and provide an opinion. It’s better to be upfront in the initial cover letter saying, “What is your medical opinion of the evaluation performed by Dr. Smith on Sept. 1, 2020?”
5.Strengthen the defensibility of your IME report.
Payers want IME reports that can hold up in a court of law. There are many issues in the cover letter that can diminish the defensibility of your IME result:
- Influential or leading questions. A cover letter is discoverable and can be subpoenaed. As such, you don’t want someone drawing the conclusion that an IME result was influenced by information in the cover letter. For example, avoid leading questions, which prompt or encourage a specific answer in the IME report. Instead, questions must be clear and simple, contain factual and documented information from the claim or medical record. If it’s a leading question, rephrase it, so it’s open-ended and doesn’t suggest a particular answer.
- Lack of medical rationale. IME physicians should provide medical rationale in support of their perspective. If it’s not included, the door is open to discredit the physician’s opinion. It’s understandable that IME physicians might forget. In their daily practice, they don’t need to provide medical rationale in files. To avoid this problem, simply ask for it in the cover letter: What’s the medical rationale that supports your medical opinions?
- Incorrect Information. If you provide incorrect information in your cover letter – such as an incorrect body part, wrong side of the body (right vs. left), misspelled name, or inaccurate date of injury – IME physicians are likely to use the same incorrect data in their IME report, which can discredit the report. Double check your information. Again, if you send your cover letter early, your IME vendor can serve as an extra set of eyes to catch mistakes.
- Requesting addendum after addendum. This practice can imply that requesters were providing only limited information in hopes of obtaining a desired medical opinion. Then they provided more information only because they had to. This may seem suspicious, especially if the added information ends up changing the physician’s opinion toward the claimant.
6. Provide training on how to develop well-structured IME cover letters.
As we’ve outlined in this article, there’s a lot that IME requesters – including adjusters, case managers, and attorneys – can do to improve the quality of their IME reports. These strategies start with understanding the importance and best practices around developing a well-structured IME cover letter.
Workers’ comp program managers, claims managers, and branch/office managers can help by providing their staff with appropriate training on how to appropriately craft and hone this important communication with the IME physician. You can start by forwarding this article to team members and reaching out to IME vendors, like ours, for more in-depth training on this topic.
About Richard Leonardo
Richard Leonardo is Senior Vice President of IME and Specialty Services for Genex Services. He joined in the company in 2019 and is a highly experienced executive with proven success directing sales and operations. With more than 20 years of experience, he has extensive knowledge of the insurance and managed care industries. Leonardo previously served as CEO of Ascential Care Partners and also held senior leadership positions at FairPay Solutions, Express Scripts and Healthcare Solutions. He began his managed care career with FairPay where he led the revitalization of the business, automating the specialty review process which led to significant profitable growth and an eventual sale to Mitchell International.
About Genex Services
Genex Services (www.genexservices.com) provides best-in-class clinical solutions that enable customers to transform their bottom lines while enhancing the lives of injured and disabled workers. Genex, a clinical management leader throughout North America, serves the top underwriters of workers’ compensation, automobile, disability insurance, third-party administrators and a significant number of Fortune 500 employers. In addition, Genex clinical services are enhanced by intelligent systems and 360-degree data analysis. Its clinical expertise 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. Genex, Mitchell, and Coventry have recently combined their joint industry expertise and advanced technology solutions into one organization to simplify and optimize property, casualty and disability claims processes and services.
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