Most workers’ compensation (WC) claims proceed without issue,but disputes can arise on complex cases that amass significantmedical and indemnity costs.

In these situations, employers and their insurers want to fairlycover the injured worker’s medical care and time away from work,and ultimately return the individual to full duty if possible. Atthe same time, they want to guard against covering conditionsunrelated to the injury, inappropriate treatment or potential abuseof the system.

Enter the independent medical examination or IME.

Typically, IMEs are requested to help address issues ofcausation, return-to-work (RTW) restrictions, permanent impairment,the appropriateness of treatment and whether maximum medicalimprovement has been reached. When used appropriately, IMEs are anoutstanding tool for managing medical claims and can deliverbenefits to employers and injured workers alike. Obtaining aquality IME, however, is not as simple as just scheduling anappointment with the local surgeon.

Although all physicians are licensed and trained in medicaltreatment, only a limited number have the expertise and know-how toperform an IME resulting in a medico-legal report that helpsresolve claim disputes. Claims professionals can waste time tryingto identify the right IME expert and still not end up with aquality, objective report. As a result, companies specializing incoordinating IMEs and providing quality oversight have evolved toassist in this effort.

When ordering an IME, two factors are critical to ensure aneffective outcome:

• Initiate requests early. Once a claim is on acertain course, it’s difficult to make a drastic change indirection. We’ve seen situations in which claimants have receivedWC benefits for years on claims that were never properly evaluatedand should not have been medically accepted in the first place.When causality is in question, a pre-existing condition issuspected or treatment begins to deviate from normal standards ofcare, an early IME can clarify issues upfront to help with claimsdecisions.
• Provide purpose and background. To obtain auseful result, it’s imperative to provide examining physicians withclear objectives and any specific questions that must be addressedin the final report. Is the exam to determine whether furthermedical care is needed, the level of permanent disability or otherconcerns? Is an impairment rating needed? It’s also helpful tolimit questions to keep the objective in focus. Additionally, thephysician should receive all relevant background documents,including a complete medical record, test results, job descriptionsand claimant statements, well in advance of the exam.

Evolution of the IME industry

The WC industry has at times been suspicious of IMEs, believingresults can be swayed to either dispute or support one’s case. Atother times, IMEs have been viewed to waste time and resources. Howcan the industry obtain clear, objective medical evidence to assistin claim decisions?

This demand for quality IMEs has given rise to a serviceindustry aimed at connecting the best, most qualified physicians toorganizations requesting these exams and to claimants who mustundergo the evaluations. Although the basic function of the IME hasremained the same, the nature of the industry has evolved to meet agreater demand for quality and objectivity.

In the past, IMEs were ordered in a highly fragmented market,populated by many small and relatively unsophisticated players.Today, the industry is under tremendous pressure to meet new andevolving state and jurisdictional requirements, as well asstandards for quality, privacy and data security. As a result, IMEcompanies have had to evolve and consolidate to become clinicallyfocused and responsive to industry needs.

Consequently, WC insurers have moved from using many IMEcompanies to establishing a preferred list of best-in-class IMEcompanies with extensive geographic reach, a breadth of medicalexperts, clinical coordination, quality processes, efficientworkflows and advanced technology platforms. Consolidation hasenabled sophisticated IME companies to emerge that have structuredtheir enterprises to provide the following benefits on a nationalbasis:

• Quality providers. An IME company hasrelationships with a broad pool of medical experts. It evaluatesand credentials physicians to make sure that they’re skilled atperforming IMEs; do not have a sanction against their license, andhave an active treating practice. The company has fosteredrelationships with providers, so it is familiar with their areas ofspecialty, board certifications and expertise on body parts, suchas orthopedic surgeons who are specialized in hands versus knees.As a result, the IME company can promptly schedule an appointmentand obtain a quick response.
• Clinical coordination. The IME company ensuresthat the exam addresses all pertinent clinical issues. Trainedclinical coordinators organize medical records, highlight criticalpieces of a file and identify the items that specifically should bereviewed and considered by the examining physician. For example, ifthe purpose of the IME is to assess causality, the coordinatorensures that appropriate diagnostic tests and medical reports areavailable and complete.
• Quality assurance. IME reports must be wellwritten. The medical opinion is solely that of the examiningphysician; however, the IME company will review reports to ensure aconcise, accurate and clear medical opinion that addresses all theissues at hand and sends any questions back for the provider toaddress The final IME report is vetted through a clinically focusedprocess to provide a quality end result.
• Jurisdictional expertise. The IME company hasin-depth knowledge of various jurisdictional requirements, such aswhen, why and how often IMEs can be requested. Each jurisdictionmay use different evaluation guidelines, such as differing versionsof the AMA Guides to Disability and Permanent Impairment, and mayrequire different language and notifications. If state rules arenot followed, for example, if the claimant is not given sufficientadvance notice, an IME may be disallowed.
• Efficiencies. A sophisticated IME company hasconsistent, efficient processes across a national marketplace. Itstreamlines workflows around scheduling, intake, coordination,quality assurance and report delivery—all of which minimizes delaysand improves communication throughout the process.
• Accreditation. As the bar for servicecontinues to rise, sophisticated IMEs have obtained externalaccreditation. Through organizations such as URAC, an IME company validates its useof best practices regarding data security, quality businessprocesses and HIPAA standards. For insurers looking to create ashort list of IME vendors, URAC accreditation offers a stamp ofapproval that the IME company meets high quality standards.
• Infrastructure. An IME company should makestrategic investments in data security and systems to better managethe IME process. Best practices include the use of secure portalsfor exam scheduling and efficiently transferring records, documentsand reports for the IME physician to review.

WC industry consolidation, changing jurisdictional requirementsand an ongoing demand for quality, impartial IMEs continues todrive change. The most successful IME companies continue to adaptto meet these industry needs.

To ensure a quality process, insurance companies should chooseIME vendors carefully. Strategic initiatives have shifted theperspective of IME companies to trusted providers of medicalopinions that guide the direction of claims and get injured workersthe care they need to recover and return to work.

Michael Valasek is president of Med-Eval, Inc., and he canbe reached at [email protected].Steffen Nelson is president of Objective Medical AssessmentsCorporation, and he can be reached at [email protected].Both companies are divisions of GenexServices.