Examining the Exam: It’s Time to Rethink the IME

02.12.2016


By ARCHIE ANDERSON

Traditionally used as a critical second opinion in workers’ compensation, the independent medical exam (IME) is a standard strategy often used as a last option to address lingering and high-cost claims.

Yet because of the severity of injuries in cases requiring the exam, the IME has increasingly come under harsh criticism from those who argue it’s simply a cost-cutting tool designed to meet the best interests of the employer rather than the claimant.

As an industry, we need to address these concerns through transparency, better communication, and a more strategic and thoughtful use of IME. We also need to take a closer look at the IME and when it can be used most effectively during the claims process. The result will be better care for injured workers and better claims resolution for payers and employers.

Key Tips in Using IME
To reach this goal, we need to review how use of the IME has changed over the years. The following five trends can help build stronger and more effective workers’ compensation programs.

Mind the models. There are two different business models for IME: clinic and network delivery. Under the clinic model, claimants are sent to providers at medical clinics owned and/or operated by IME companies where reviewing comp claims may be their primary role. There are two schools of thought on the clinic model. Since they specialize in IME, providers who work at these facilities can be seen as experts who thoroughly understand the nuances of comp, but others consider them biased toward the payer or employer. In the network model, claimants are seen by independent specialists, mostly medical providers in active practice who examine the claimants at their office site, often with training or expertise in a specific injury or illness. Some companies mix and match–they will deliberately select a model for each claim.

Tip: Choose carefully, determining which model best fits your IME utilization strategy. Network models may help you avoid perception of bias and provide assurances the IME is an optimal review of the case. The clinic model may ease the scheduling process and increase convenience for claimants and the appropriate providers. No matter the model you choose, try to use local physicians who understand the market, follow guidelines and strive to meet community standards.

Match provider with injury. There is an adage in the health care industry that also applies to workers’ compensation: Use the right provider for the right injury at the right time. For example, a general practitioner is not equipped to offer the same quality of review for traumatic brain injury (TBI) as a neurologist who specializes in TBI.

Tip: Encourage adjusters to identify an IME provider who is a “specialty-to-specialty” match of the treating physician. This will save time and money, and also make the exam more viable should the claim reach litigation or settlement discussions.

Start the process earlier. Historically, IMEs are conducted two or more years after a claim was initiated. That may be too late. Bringing in expert managed care partners to help analyze your data and industry trends can help highlight claims that can go off track and result in high costs. That same data analysis can also identify claims that may benefit from an earlier IME resulting in earlier RTW. When an expert specialist can show a treating physician the value of an alternative approach, new therapies and modalities may be incorporated into the treatment plan, improving outcomes and, potentially, lowering costs.

Tip: Conduct the IME earlier on complex claims so the results may be used as a medical “Sherpa” for treatment physicians.

Consider comorbidities. One of the most challenging and controversial aspects of claims resolution is determining whether a worker’s injury occurred on the job or is the result of a pre-existing condition. An IME can help clarify the cause of a workers’ compensation injury.

Tip: Employers need to take every step possible to ensure their IME utilization is focused on what’s best for the injured worker. The process should be transparent and comorbidities found to contribute or cause an injury must be supported by medical findings and appropriate steps taken to resolve the claim.

Develop an IME strategy. Lingering claims with no clear resolution date are costly. A strategy that incorporates IME to better identify when to settle or how to resolve a claim can help payers set reserves and ensure employers have better data for planning. Early IME intervention sends a message to claimants and treating providers that the employer is taking the worker’s injury seriously and will be watching its progress.

Tip: Use your data and work closely with your managed care vendor to identify claims at risk of becoming costly and use an IME to address those claims.

Making the Grade
A more focused and timely use of IME is a strategy worthy of consideration by employers and carriers seeking to improve workers’ compensation programs. It often results in a better treatment protocol for the injured worker, faster and favorable resolution of a claim and stronger protection against litigation.


ABOUT THE AUTHOR

Archie Anderson, Senior Vice President of Specialty Services at GENEX Services, LLC, has more than 28 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. Anderson 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.

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Comments

In Texas the carrier may request a Designated Doctor Exam to determine;
extent of injury
disability as a direct result of the accident
whole person impairment rating and or
return to work.

If the Exam results to be in favor of the patient then the carrier and request that the Texas Department of Insurance that they approve for the carrier to send the claimant to a Required Medical Exam (R.M.E.) the exam will be conducted by a physician of the carrier’s choice.  If the RME results in the claimant’s favor the carrier will. then send medical records to a peer review doctor.

On balance the carrier is allowed to go fishing with no fish in the pool.

 

juan c. gonzales

2016 02 19

We are a group occmed/orthopedic practice which performs IME’s routinely. I agree with this article and its recommendations.  Matching specialty to the treating physician is a good suggestion as long as the IME physician is trained in causation analysis presuming the IME issues are related to that issue.

Gary Tipton

2016 02 21

Maryland’s system is simply and exercise in dueling doctor’s. We have many of the best doctors in the world in Maryland. Sadly, the medical fee schedules often prevent the most qualified physicians from accepting workers compensation cases. Also, many of the best providers don’t want to be involved in appellate litigation. Sadly, many of the claimant’s and defense bar have their group of go to quacks. I have always tried to find mutually agreeable physicians to do consultative exams. It speeds the process and make the case less likely to end up on appeal. The first step is to improve the fee schedules

Joel Fader

2016 02 21

Great article with several outstanding tips. Only one point that may not be entirely accurate…While specialty to specialty makes intuitive sense and is critical in Standard of Care determinations, Best Practice and causation for claims management is best determined by a specialist of the definitive specialty. For instance, for TBI, it would be the neuropsych doc. For MSK and spine conditions, it is the subspecialist surgeon. It is these definitive subspecialist who are ultimately responsible for determining a definitive diagnosis, overseeing a treatment plan on the treatment side, a be definitive in testimony.

Stan Lee, MD

2016 02 23

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