Independent Medical Exam (IME) Mistakes – Dozen Blunders

An independent medical exam can make or break a WC file. Yesterday, I wrote a list of the Top 10 Ways that IME’s can harm a WC file. The first five from the article are covered more in-depth today. These Independent Medical Exam suggestions may not fit all files in all states.

Can backfire if the claim is from a state that allows directed medical care. If you have an employer-directed care state, then the IME is basically a 2nd opinion on your own opinion. Obtaining a 2nd surgical opinion is a different matter. Establishing a physician treatment network and using it will avoid IME’s on your own directed care. The injured employee should be receiving treatment from your approved medical providers when using the treatment network to its fullest.
Performed on a very old claim with no prior IME’s. Waiting for years to schedule an IME will lessen the validity of the exam. How can one expect to question a physician’s opinion or treatment plan with a single out-of-date IME? The treating physician has been seeing this patient for years. How can one appointment question a long-established treatment plan? The WC courts usually detest seeing these and will usually rule with the treating physician’s opinion.
Not discipline-specific – if the treating physician is, for example, a neurosurgeon, the best IME will be provided by another neurosurgeon. An orthopedic opinion may not necessarily hold the same weight. There are so many IME physicians available in most parts of the country.
Wikipedia – goodcatmum
Takes the claim on a tangent – there are files where the IME physician identifies non-related medical conditions and has other incorrect info that is actually written in the IME report. See #5 for how to avoid having an IME actually causing more problems than it helps prevent overall. These do happen now and again and are sometimes unavoidable.
Starts with one of those form letters – not good. Spending a large amount of time and money can be easily fettered away by using a form letter. The specific information needed may not be enumerated in a pre-filled form letter. As there is so much on the line with an IME, a letter that covers the file and medical history is a great idea. The physician should not be solely relied upon to come up with a report without some input in the IME appointment letter. Sending a form letter for an IME will raise the risk of #4 occurring on the file. Ask the questions you want to be answered by the IME physician.
The IME physician may not like the fee schedule – some states allow the fees to be negotiated directly without using the fee schedule. This may be a good idea as nothing can sour a relationship with an IME physician that feels shorted in what they were paid to see the injured employee. Do not assume the IME physician will just accept a set amount. This should be negotiated upfront and please do not wait 60 days to pay for the IME appointment.
The court has seen reports from the same physician too many times. WC umpires, judges, and commissioners are very adept at noticing a trend where a certain employer, carrier, or TPA (Third Party Administrator) sends all of their inured employees to the same IME physician. That is not a trend you want to establish overall. There are so many IME physicians to choose from in most areas.
The treating physician is not informed an IME has been requested for a 2nd Opinion. An act of great courtesy is to inform the treating physician that you are requesting an IME. Almost all physicians will not take offense, especially if the IME is a surgical second opinion. In fact, the treating physician’s office may even recommend an IME physician. The relationship between the carrier/TPA/employer and the treating physician is very important to return the employee to work as soon as practical.
Does not have all the medical records included with the IME request letter. This is a big potential mistake as the IME physician is going to base a large proportion of their opinion on a review of the medical records. One of the most overlooked types of medical records is the radiological studies. The review of the medical records that accompanies the IME appointment letter is beyond crucial. Leaving out one report can take a file down the incorrect path very quickly.
Is rushed so heavily the IME physician is not given time to review records and do a full report. An appointment should be scheduled far enough in advance to give the IME physician record review lead time. Copying/scanning the records and writing the proper IME letter (an art) takes time if done properly.
123RF
Bonus – Not involving the rehabilitation nurse– Most rehab nurses will know who the best physician in the area for the type of IME that you have requested for the injured employee. The rehab nurse is invaluable in these instances. If she/he has a working relationship with the IME physician’s office, that is golden for having successful IME. The injured employee will also likely heavily trust the rehab nurse’s recommendation.
Bonus – Sloppy records- See #9 above – the easier you can make the review of the medical records for the IME physician, the better the results for all involved. Ordering the notes from oldest to newest is a great idea. Using tabs will also result in a better IME appointment.
Bonus – Not following up for the results – in some of our recent file reviews, we noticed that the adjuster may forget to follow up to discover the results of the IME. Waiting for the report to arrive may delay any file developments for 4 – 6 weeks. We have noticed that many adjusters are not diarying the IME follow up actions such as reviewing the IME report or even requesting it. Do not rely on the IME physician’s office to forward the report.

Please note that each state has its own rules on Independent Medical Exams that should be followed. These two lists were just general recommendations.

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One Thing Not To Do On Your File Reserves

Working in a Claims Dept for many years, I had seen one thing that would totally backfire on an employer that had questions on their Workers Comp file reserves. If you have established a working relationship with your Workers Comp claims adjuster, the following may not apply.

The National Archives

The one thing to not do centers around not being prepared. Calling your Workers Comp claims adjuster without being prepared to discuss the reserving on the file will usually cost your company more in premiums. Please remember that the Workers Comp adjuster is very similar to calling your bank’s loan officer. The issue of credibility is critical. Being prepared = credibility.

The easiest way to prepare is by reviewing the Workers Comp loss runs. Usually, the loss runs do not have a status. You can email your adjuster and ask for a status on every claim or obtain online access to your claims. You should be able to see what is happening with your claims online.

How do you know what Workers Comp reserves are correct? That is a very tough call. It takes most insurance adjusters 5 – 7 years to gain enough experience to set the reserves on files. Setting reserves is a tough business. If you do not feel comfortable having this discussion, please call a Workers Comp audit expert. As I said before, negotiating your Workers Comp reserves is like talking with your bank. It will directly affect your budget.

Finally, the one thing to not do is to just call up the adjuster and confront him/her that your reserves are too high.

Picture Business Meeting One Thing File Reserves

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This person is responsible for the reserves on your Workers Comp files which feed into your E-Mod that directly affects your insurance budget. This tactic can sometimes backfire.