If you partner with an effective IME vendor, the claimant will be sent to a physician who is highly qualified and skilled at performing these exams.

When claimants arrive for an IME, these physicians explain the purpose of the exam and that it was requested by the insurance company (or payer). They inform claimants that they’ve spent significant time reviewing their medical files, that they’re going to perform an evaluation and provide the findings to the requesting company. If claimants want a copy of the results, they can obtain it from the insurer.

Although IME physicians are not facilitating treatment, a quality IME still provides significant benefits to 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, the IME can lead to injured workers getting the treatment they need sooner, which is a significant benefit to their well-being.

The Physician Perspective: Expert Opinions Based on Reasonable Medical Certainty

In this Part 3 of our series on quality IMEs, we interviewed two premier physicians to get their thoughts on what constitutes a quality IME process.

“For me, preparing for an IME starts three or four days before the actual exam,” said Amir Reza Moinfar, MD, of Elite Orthopaedic & Musculoskeletal Center. “I start by reviewing medical records. In some cases, these files can be on the order of up to several thousand pages. It’s a good opportunity to familiarize myself with the particular claim and to potentially catch items that may be missing from the file. For example, if I’m going to assess whether a claimant can return to full duty, I need the job description. If a claimant has had surgery, I need to most certainly have access to the operative note. There’s still time to request any missing information in advance of the exam. This helps to make the process, in my opinion, more seamless, thorough and efficient.

“When an IME physician gives an opinion, it needs to be based on medical evidence and based within a reasonable degree of medical certainty. There are legal ramifications that help hold an IME to a high standard,” explained Moinfar.

“There’s a certain skill set that’s required in performing these exams,” he added. “Much of it comes with experience, but a lot of it comes from proactively going out of your way to learn and become as proficient as possible in performing these exams. I chose not to perform IMEs straight out of training. First, I wanted to feel confident in my ability to treat patients and formulate decisions with their care. There are also legal terms an IME physician must become familiar with, such as causation, disability, impairment, and apportionment. These things aren’t taught in medical school, but a physician can take courses and study on the practice of performing quality IMEs. Also, I feel that a lot of the skills associated with performing IMEs come with experience.”

We also spoke with Ghazala Kazi, MD, MPH, of Medical Advisory Services. “I’m an occupational medicine physician so performing IMEs is my specialty,” she explained. “I’m trained to determine work-relatedness. I don’t always conclude that a condition is not related to work. In fact, most of time I conclude that it is work-related. With those cases, the insurer can proceed in providing the claimant with treatment. I’m helping the insurance company make a decision, and I’m helping the claimant, who may have been struggling for months, or even years, to get the care they need.”

She also discussed the importance of having a complete claimant medical record in order to determine causation: “The file should include the accident report and all relevant diagnostic tests, such as any MRI or CT scan reports. If I’m evaluating a claimant’s respiratory system, it’s critical to have the pulmonary function test reports. If there are tests conducted prior to the injury, it’s important to receive those reports as well. Let’s say I’m asked to determine if a person’s hearing loss is work-related. In that case, if a baseline test was performed at the time of employment, I need the results of that test to make the determination.

“Sometimes, if someone is injured, the mechanism of injury is obvious,” noted Kazi. “However, there are complex cases, where I have to review studies to determine if there is a causal relationship between the condition and the work environment. An IME physician who has the knowledge and training in epidemiology understands the methods to draw this conclusion and is trained to read such studies. Only a physician with the right expertise can perform this type of analysis.”

The method that Dr. Kazi is referring to is the Hills Criteria for Causation, a set of nine criteria that provide epidemiological evidence of the relationship between a presumed cause (e.g., a work-related accident) and the observed effect (the worker’s injury).

Bridging the Quality Divide

Over the course of our three-part series on IME best practices, we’ve outlined how you and your organization can bridge the divide and consistently obtain a quality IME result.

When looking for a place to initiate these changes, it’s essential to start at the beginning and refine the process by which you request these exams. From there, ensuring that you are utilizing a sophisticated IME vendor is another important step. A quality vendor is essentially the conduit to getting your injured workers matched to the best, most-qualified IME physicians – resulting in an IME that drives informed decisions and moves claims toward closure.

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The demand for quality has given rise to an IME service industry aimed at connecting the best, most-qualified physicians to organizations requesting these exams and to the claimants who must undergo the evaluations.

Although the basic functions of the IME have remained the same, the nature of the industry has changed tremendously to meet demands for a greater level of service and clinical excellence. In fact, workers’ compensation (WC) insurers have moved from using many small mom-and-pop shops to establishing a preferred list of best-in-class IME companies that have an extensive geographic reach, a team of medical experts, clinical coordination, quality assurance processes, efficient workflow and an advanced technology platform.

As sophisticated IME companies – like MCN – have emerged, they strive to structure their enterprises to facilitate a quality IME each and every time – which provides significant benefits to the industry. Criteria for enabling a quality IME include the following:

Objectivity. When requesting an IME, objectivity is of utmost importance. If you work for an employer or insurer and request an IME directly from a physician, there’s a perception that you’re recruiting and paying this doctor to provide a specific medical opinion. Whereas, if you engage a third-party IME vendor, impartiality is built into the process. This 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. They simply recruit the most qualified expert to provide an independent, impartial opinion.

Quality Providers. A quality IME company will have relationships with a broad pool of medical experts. It evaluates physicians to make sure they are skilled at performing IMEs, don’t have sanctions filed against them and have active treating practices. The IME company is familiar with the physicians’ areas of specialty, board certifications and expertise on body parts, such as orthopedic surgeons who are specialized in hands versus knees.

Clinical Coordination. When an IME is ordered, the vendor has trained clinical coordinators who help to organize medical records, highlight critical pieces of the file, and identify items physicians should specifically review and consider in relation to the IME objective. For example, if the purpose is to assess causality, the coordinator will ensure all diagnostic test results are included and available for the physician to review.

Quality Assurance. The vendor ensures that the final IME report is carefully vetted through a clinically focused process to ensure a quality end result. Obviously, the medical opinion is solely that of the examining physician. However, the IME company will review the report to ensure a clear medical opinion is expressed and that the report addresses all the questions put forth by the claims staff.

Jurisdictional Expertise. The IME company must have in-depth knowledge of various jurisdiction requirements, such as when, why and how often IMEs can be requested. Each jurisdiction may use different evaluation guidelines, language and notifications. If state rules are not followed (for example, if the claimant is not given sufficient advanced notice), an IME may be disallowed.

Efficiencies. A sophisticated IME company has set up consistent, efficient processes across a national marketplace. It streamlines workflows around scheduling, intake, coordination, quality assurance and report delivery – all of which minimizes delays and improves communication throughout the process. The vendor has also fostered strong relationships with IME providers, so it can promptly schedule an exam and obtain a quick response.

Accreditation. As the bar for service continues to rise, sophisticated IME companies have obtained external accreditation. Through organizations such as URAC, an IME company can validate its use of best practices regarding data security, quality business processes, and HIPAA standards. For insurers looking to create a short list of vendors, URAC accreditation offers a stamp of approval that the IME company meets high-quality standards. Currently, only a select few IME companies are URAC certified.

Digitation of the IME Process. A sophisticated IME company has made strategic investments in infrastructure. It has built systems and processes to work more efficiently with claims and provider communities. Digital portals have been established to securely and electronically transfer medical records between claims staff and IME physicians. These portals significantly streamline workflow, as the process of copying and shipping medical records is eliminated.

While quality vendors lead a march toward excellence, others lag behind. Using a “lagging” vendor can lead to claims that become prolonged, complicated and costly – with injured workers in danger of not receiving the care they need to recover and return to work.

It’s important to understand the factors that point to “leading” vendors with whom it’s smart to partner. These companies have made it their priority to develop and consistently adhere to IME best practices. They have built processes that deliver not only savings but also superior service and credible IMEs that withstand scrutiny by state commissions, WC boards and court systems.

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As a workers’ compensation (WC) claims professional, you deal with increasingly complex claims on a daily basis. At times, you may need clarity or greater certainty on specific aspects of a case. For example, what is the true cause of a claimant’s condition? Is this recommendation the best course of treatment? Does a degree of malingering or injury exaggeration exist? In other situations, the case can be complicated by other medical issues – such as diabetes, hypertension or depression – which can hinder recovery.

Faced with these challenges, you may request an independent medical examination (IME) to help determine the next step in the claim and injury management process. In general, there are four areas where an IME can provide useful information:

• Causation. Determine if the condition, pain or other symptoms experienced by the claimant are in fact caused by the work-related injury or another medical issue.
• Treatment. Confirm if the recommended treatment falls within occupational disability guidelines (ODG). For instance, you may want a second opinion on whether a certain procedure or surgery should be performed.
• Disability. Depending on the jurisdiction and the relevant nomenclature, you may want to ascertain if the injured worker has reached maximum medical improvement (MMI), or whether permanent or partial disability exists and, if so, what is the impairment rating?
• Return to Work (RTW). Find out when the injured worker is expected to recover and return to work or determine if there might be work restrictions. For example, can the injured worker return to light, modified or full duty?

In these situations, an IME serves as an outstanding tool to help make difficult decisions, while also providing significant benefits to both the employer and injured worker.

IME Quality Overrides IME Controversy

With complex cases, claimants may seek legal representation. In these situations, opposing sides may obtain IMEs to substantiate their respective opinions. As a result, a certain amount of contention and suspicion has come to surround the IME process, with some WC professionals feeling the exams further complicate a case. Rather than bringing about clarification, some say decisions get bogged down and stalled, and injured workers get caught in the middle – not receiving the care they need in a timely manner.

Due to these issues, the WC market has begun to demand an increased level of quality in the IME process. Quality ensures the original intent of these exams – which is to obtain an impartial, expert medical opinion that will help determine the next step in the case.

In this three-part series, we review best practices that must be followed to ensure a quality IME result. Currently, a quality divide exists in the industry. On the “leading” side of this divide are organizations striving to establish and consistently adhere to quality standards. On the “lagging” side are those unaware that such standards exist and, as a result, unknowingly end up with less than optimal IME results. To bridge this divide, we need greater awareness, understanding and support of the key factors contributing to quality.

Three Sides to a Quality IME Process

Currently, there are three stakeholders that play an integral role in producing a quality IME. Whether these parties are leaders or laggards is largely dependent on whether they acknowledge and support the quality criteria under their control.

• Claims staff – observe a quality approach to requesting IMEs
• IME vendor – envision, put forth and champion new standards of IME quality
• IME physician – perform a thorough exam, provide an expert opinion based on evidence, and clearly address the stated IME objective and questions

In Part 1, we look at the quality criteria championed by claims staff like yourself.

The Claims Perspective: Ensuring the Right Stuff

In workers’ compensation, injured workers may often receive or have an opinion about their condition, treatment or ability to return to work. This opinion may not be supported by existing medical evidence. In other words, it’s being called into question or at least needs to be confirmed. This opinion could be based solely on the injured worker’s perception, or it could be supported by the treating physician and/or an attorney representing the case.

Working on behalf of the employer and payer, the claims professional strives to fairly cover the injured worker’s medical care and time away from work, but you also want to guard against conditions not covered by WC, as well as inappropriate treatment and potential abuse of the system.
When opinions are in question, it’s time to seek an IME to provide a third-party perspective from an objective physician who’s an expert in the relevant field. Key criteria to take into account include:

1. Quality Providers. Be careful about requesting IMEs directly. If a claim is litigated, it’s vital that the IME is performed by a credible expert. Many times, you may not have transparency into all the information pertinent to ensuring the right doctor is selected. For example, do you know if certain physicians have sanctions against them, or if they’re board certified? If a vital component is missed in the provider selection process, the resulting IME could lose credibility. A simple way to avoid this problem is to use a quality IME vendor, which we’ll discuss in part two of this three-part series.

2. Timeliness. As soon as an opinion is in question, an IME should be promptly requested. For example, perhaps you are unsure about the cause of the injured worker’s pain. There have been situations where a claimant received WC benefits for years, but causation was never officially confirmed. If this step was appropriately taken, the claim might not have been accepted in the first place. However, once a case has started down a certain path, it’s difficult to make a significant change in direction. For example, if you suspect treatment is deviating from normal guidelines, it’s time to request an IME before the plan proceeds too far to be able to make a shift.

3. Clear Objective. To obtain a useful IME result, it’s imperative to provide the examining physician with a clear objective and any specific questions that should be addressed in the final report. This allows IME physicians to understand what they’re being asked to evaluate and what type of opinion they need to provide. Is the exam to determine if further care is needed, the level of permanent disability or another concern? At the same time, it’s also important to limit these inquiries so the IME physician can focus on evaluating just a few items during the examination.

4. Comprehensive Background. An IME physician should receive all relevant background, including a complete medical record, diagnostic test results, job descriptions and claimant statements — all well in advance of the exam. The records should provide a clear chronology and history, so the IME physician can accurately assess what’s going on. Is the condition improving? Is the patient fixed and stable? Does permanent disability exist? Also, it should be clear what conditions, if any, have already been medically accepted. For example, if there are four injuries, but only two have been accepted, this should be clearly indicated in the file.

When looking for a place to initiate quality in the IME process, it’s essential to start with the request itself. Are there ways you can improve this process? The practices outlined in Part 1 of our series will enable you to help enhance the quality factors under your control – and will contribute to bridging the divide, so your organization joins other leaders consistently achieving quality IME results and garnering the benefits therein.