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Home / MCNTalk / Tag: IMEs

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IMEs

April 24, 2018

Antibiotic Solutions in Soil

The first antibiotic, penicillin, was discovered almost by accident when Alexander Fleming left one of his petri dishes out while he was on vacation; he came back to find it covered in bacteria-killing mold. Now, as many infections have become resistant to antibiotics, scientists have had to wrack their brains to find more of what once was a chance discovery.

In labs around the world scientists are tasked to find new microbe-destroying molecules, but microbiologist Sean Brady has decided that maybe the answers lie outside the lab and in our own backyards.

In this article, Brady says “[His] idea is, there’s this reservoir of antibiotics out in the environment we haven’t accessed yet.” Brady and his colleagues are breaking new ground with their discovery of a new class of antibiotics they have extracted from living soil. They call it malacidins. Read more…

Tagged: antibiotics, Brady, IME, IMEs, penicillin, Sean Brady, soil Leave a Comment

February 12, 2016

Introducing MCN’s New Spokane Location

We are pleased to announce that as of this month, MCN’s Spokane, WA office has officially settled into a new home in the Hutton building located in downtown Spokane. The Hutton building is over 100 years old, steeped in a rich history we thought we’d share with you.

The history behind the Hutton building is centered on May and Levi Hutton. Born May Arkwright, May was a political activist and a prominent figure in women’s suffrage. She met Levi Hutton, a railroad engineer, in 1883 after opening a boarding house and the couple married shortly thereafter. In 1897, Levi and May invested in the Hercules Mine and four years later in 1901 they became overnight millionaires. The Hercules mine proved to be one of the largest and most lucrative silver and lead mines in the world.

The groundbreaking of the Hutton building occurred in 1906. John K. Down and Clarence Hubbell built a four-story building in Spokane upon the request of the Huttons. In anticipation of occupying the fourth floor penthouse, May Hutton deemed that “no cost would be spared” in its construction. The couple moved into their new home in 1907, and remained there until 1914. May Hutton died the following year leaving behind a prominent legacy. During the eight years that she lived in Spokane, it is estimated that May Hutton donated more than $450,000 to charity. She was also respected for her political activism and widely known for helping to secure the vote for women in the State of Washington.

After his wife’s death in 1915, Levi Hutton decided to pursue his dream of opening a home for orphaned children in Spokane. The home opened in 1919. Himself an orphan since the age of 6, Levi spent the remainder of his life caring for the children in his orphanage. He called the home “The Hutton Settlement”; it has become a model for orphanages all over the country. Levi passed away in 1928. The Hutton building remained in the family’s estate until 1969. The building underwent significant renovations in 1989 and currently houses offices and retail stores.

MCN is open for exams in this new location. Please note that our email, phone, and fax numbers remain the same. This contact information can be found below. Please do not hesitate to contact us directly with any questions or inquiries.

MCN – Spokane
9 S. Washington Street, Suite 315
Spokane, WA 99201
T: 509.747.0575
F: 509.747.1680
spokane@mcn.com

 


Tagged: IMEs, MCN News and Events Leave a Comment

April 16, 2015

MCN Celebrates Its 30th Anniversary

Members of our MCN-Northeast staff enjoy a 30th anniversary dinner and painting outing!

Members of our MCN-Northeast team enjoy a 30th anniversary dinner and painting outing!

Saturday April 18th  2015 is MCN’s 30th anniversary. It was on that date in 1985 when MCN completed its first evaluation.

From this first IME, MCN grew to become the first (in 1997) IME/peer review company with a national network, and now staffs 25 offices across the country serving hundreds of clients. In 2014 MCN delivered more than 60,000 individual services. Our network of consulting physicians now encompasses over 25,000 options in all specialties across the nation – and is continuously growing.

We are proud of our contributions to society and our communities in addressing the critical questions and challenges of disability and injury and helping to ensure appropriate care for the thousands of individuals whose claims we review and evaluate.

Over the weekend I came across two newspaper articles addressing the very core of why we do what we do. The first was a column by David Brooks entitled “The Moral Bucket List” which includes a brief reference to the Triangle Fire Factory. In response to the fire, one of the worst industrial incidents in American history, New York State established both the State Insurance Fund and the New York Workmen’s [sic] Compensation Law. These acts had ripple effects across the nation and soon many other states enacted such legislation.

The second article was “When Moneyball Meets Medicine” with the follow-up “Disability and Health Care: Calculating How Much a Life Is Worth.”  This is what we help our clients do: each report we produce is a snapshot of a life, a medical history, a course of treatment, a time when a numeric value is placed upon people. Each report we produce helps facilitate a decision that profoundly affects the injured or disabled person’s life and their ability to care for themselves.

Of course most of our days are spent in activities which seem far less profound than all this, and this is reasonable; we would end up paralyzed ourselves if we were so focused on circumstances of the individual lives whose stories cross our desks every day.

This 30-year mark gives us the opportunity to remember the larger picture of what we do and why it matters. As the founder of MCN and as an employer I am proud to have this opportunity to be of service to our society, clients and claimants.  Thank you to all of our clients who trust us with their work, and to our consultants who collaborate with us in our shared tasks.

Most importantly, we thank all the MCN staff across the country whose dedication keeps us going – as well as all of our past employees who over the decades have helped make the company a sustaining and growing organization.

Brian L. Grant MD, President and Founder

MCN's birthday arty includes a some cake!

Tagged: IMEs, MCN News and Events, MCNTalk: Introduction and Issues Leave a Comment

March 24, 2014

Courts Weigh in on Physician Responsibilities Towards Claimants in IMEs

Many who order or perform medical review services including IMEs and peer reviews hold the belief that there is no physician-patient relationship and therefore no responsibility towards the claimant. As readers will see in the article found below this post (scroll down), such a belief may, depending upon circumstances, be quite wrong.

The article, written by Rosemary Gafner, Ed.D. and James E. Schutte, Ph.D. of Medical Risk Management, Inc./Medrisk identifies the limited duty of care and other responsibilities that physicians may have in the course of their work. The cases cited are fascinating and demonstrate that beliefs that one may hold, or even try to put into contractual language, may differ from the findings of a court when presented with case-specific facts. Such circumstances are rare, but they will occur from time to time and it is essential that they be properly managed.

Another way to look at this is putting oneself in the shoes of the claimant, when during an examination, one uses ones medical skills to learn of a life impacting or threatening finding not already known to the claimant. And the cases suggest that delegating notification may not suffice and that it may be best to personally ensure that one’s concerns have been shared – and fully documented.

We urge those who order IMEs and those who perform them to read Gafner and Schutte’s article carefully. If in doubt, inform, document and communicate to all parties, including the referring party, the claimant, treating physicians (subject to consent), and the IME company who organized the evaluation. Document in the report what has been done. If in doubt, consider asking for legal advice from one’s personal attorney or malpractice carrier. Malpractice carriers are quite interested in providing proactive risk management advice rather than defending preventable suits.

As we recently reported in MCNTalk in a case of a tumor being discovered, the outcome can be both professionally satisfying and in the clear interests of the claimant.

We are very grateful to Rosemary and James for permission to reprint their article. Not only will you learn about potential duties to claimants, but about duties to third parties,  ex-parte communication errors and other relevant topics. I encourage you to visit their site. And if you wish CME credit, for a fee, by answering questions on the article, you can find the specific unit here: https://www.medrisk.com/medrisk/d0b7bb34-80be-41a6-94d7-57c17fba7812.aspx

Brian L. Grant MD

INDEPENDENT MEDICAL EXAMINATIONS

Many clinics offer or even specialize in medical services that are ordered by, paid for by, and performed for the benefit of third parties. Known as independent medical examinations (IMEs), such services range from pre-employment or insurance physicals and drug screenings to the evaluation of claims for worker’s compensation or other disability benefits to the assessment of injuries claimed by a plaintiff in a lawsuit.

In a normal provider-patient relationship, the physician or other healthcare provider owes a clear and unequivocal duty to act in the patient’s best interest. In an IME, however, the provider also owes a duty to the party paying for the exam, whose interests are often adverse to those of the examinee. While this is not a standard physician-patient relationship, you still owe at least a limited duty of care to the examinee/patient. In addition, as we’ll see, there are several circumstances that can transform an IME into a physician-patient relationship in which there may well be a conflict between your duty to your patient and that owed to the third party. And even in the absence of a provider-patient relationship, you still owe a duty to protect the examinee from harm.

The Concept of a “Limited Duty of Care”

The AMA’s position on a physician’s duty to the examinee during an IME is spelled out in a 1999 opinion published by its Council on Ethical and Judicial Affairs:

“When a physician is responsible for performing an isolated assessment of an individual’s health or disability for an employer, business, or insurer, a limited patient-physician relationship should be considered to exist.” It goes on to state:

“The physician has a responsibility to inform the patient about the important health information or abnormalities that he or she discovers during the course of the examination. In addition, the physician should ensure to the extent possible that the patient understands the problem or diagnosis. Furthermore, when appropriate, the physician should suggest that the patient seek care from a qualified physician and, if requested, provide reasonable assistance in providing follow-up care.”[1]

While AMA positions are not legally enforceable, the courts may refer to them to determine what the medical profession itself considers to be the standard of care in a given situation. Indeed, the courts have repeatedly referred to this AMA position outlining a limited duty of care to decide cases in which claims have arisen out of independent medical examinations.

A case in point is that of Andrew James, 27, a heavy equipment operator whose company had sent him to gastroenterologist Marcus Mason’s clinic for a pre-employment physical.[2] Mason ordered a chest X-ray, and the clinic radiologist who interpreted it observed cardiomegaly—of which James was already aware—and a widened mediastinum, which can be an indicator of lymphoma in men in their 20s. James was not aware of this latter finding.

Mason reported back to the company that the X-ray had been abnormal, but only noted the presence of cardiomegaly, not the widened mediastinum. A few days later, the company informed James that he was in good health, and he was hired.

Six months later, James was referred back to the clinic with complaints of flu-like symptoms and a weight loss of 25 pounds. This time, a chest X-ray revealed a large mass in the mediastinum, and a diagnosis of stage IIB Hodgkin’s disease was ultimately made. The patient died of the disease 8 months later, and his widow sued Mason and the clinic for failing to inform James that he had warning signs of lymphoma during his first examination.

During the subsequent trial, Mason argued that the clinic’s contract with the company stated that the clinic’s only duty was to report the examination findings back to the company, and that it was the company’s duty to communicate those findings to the examinee. The trial court allowed the jury to consider the contract between the company and the clinic to determine whether the physicians’ conduct had been reasonable, and the jury found in the defendants’ favor.

The plaintiff appealed, and the higher court determined that the jury should not have been allowed to examine the contract because it was in violation of the AMA’s position that the examining physician has a non-delegable duty to inform the examinee of any significant findings. Only another physician who has been fully apprised of the findings and agrees to follow up with the examinee can relieve the examining physician of that duty. Therefore, the contract between the company and the clinic was legally unenforceable and void. The verdict in favor of the defendants was reversed and the case ordered retried.

This case raises an important point: It is common for third-party companies, especially those involved in an adverse relationship with the examinee, to contractually relieve or even prohibit the examining physician from sharing any findings with the examinee. Be advised that such a contract would place you in direct violation of medical ethics unless it specifies a physician who will carry out that duty in your place. Therefore, you should never enter into an arrangement of this kind and, if you do, realize that the contract will not protect you against a claim that you failed to advise the examinee of an important health issue. In fact, such a contract might even be used against you in court to paint you as an unethical and irresponsible physician.

The danger of a “limited” physician-patient relationship, as defined by the AMA, is that the mere act of providing someone with medical advice may be enough to create a standard physician-patient relationship. This means that, in fulfilling your limited duty, you run the risk of creating a full-fledged duty of care.

Simply advising the examinee to seek follow-up care will likely not incur such a duty. For example, the courts held that FP Reginald Frankel did not create a physician-patient relationship by informing examinee Agnes Blaine that she had tested positive for tuberculosis during her pre-employment physical.[3] The trial court’s decision, upheld on appeal, was based on the fact that Frankel had simply informed Blaine of his findings and advised her to seek a second opinion from her own doctor.

When you do provide such warnings, however, you must make clear to the patient the gravity of the situation and the need for prompt follow-up, as shown by the case of Joseph Mahan, a real estate agent and part-time model, who underwent a physical exam by internist Derrick Haynes.[4] During the exam, Mahan asked about a 3 mm mole on his left earlobe. Haynes examined the mole and, aware that it could be melanoma, strongly suggested that Haynes see a dermatologist. However, Haynes did not specifically explain the possibility that the mole was cancerous.

Mahan did not see a dermatologist until 6 months later, when the mole was removed and diagnosed as malignant melanoma. He had to undergo extensive ear and neck surgery, which left him unable to find work as a model. Mahan then sued on the allegation that the diagnosis of melanoma was delayed because the internist had failed to adequately warn him about the dangers of not going to a dermatologist immediately. A jury awarded Mahan $730,000. An appeals court upheld the verdict after finding that the physician had a duty to ensure that the patient understood the seriousness of the situation and the potential consequences of not seeking prompt follow-up.

While warning the examinee to seek follow-up care from another doctor generally won’t create a physician-patient relationship, providing medical advice or becoming involved in the examinee’s treatment probably will. A case in point began when orthopedist John Warden examined Don Krug to determine his eligibility for worker’s compensation.[5] Krug complained of back injuries, and Warden suggested physical therapy and even recommended a specific therapist.

Following therapy, Warden again evaluated Krug and determined that his condition had improved to the extent that he was able to resume his regular job without restriction. Krug did so, and his return to work either caused or exacerbated a previously undiagnosed herniated disc, necessitating surgery. Krug then sued for malpractice, alleging that he was prematurely and negligently advised to return to work.

Warden applied for and received summary judgment on his argument that he owed no duty because he had not directly treated the plaintiff. However, an appeals court found that Krug had presented a plausible argument that the doctor had provided him with medical advice, and that Krug had relied on that advice to his own detriment. The higher court overturned summary judgment, ruling that it should be left to a jury to decide whether Warden’s actions constituted malpractice.

Even telling an examinee that he does not need treatment might be construed as establishing a physician-patient relationship. In one case, for example, an orthopedist under contract with an insurance carrier evaluated a worker’s job-related shoulder injury annually for several years.[6] After each exam, the doctor advised both the insurance carrier and the worker that surgery was not indicated.

Eventually, the worker sought an independent evaluation of his injuries, which resulted in surgery on his shoulder. He then sued the orthopedist for malpractice and the insurance company for intentionally delaying needed medical care. The trial court granted the defendants summary judgment, which the plaintiff appealed.

The appellate court upheld summary judgment for the insurance company, finding that they had reasonably relied on the orthopedist’s medical reports in denying payment for the plaintiff’s surgery. As for the doctor’s claim that he owed the plaintiff no duty, the appellate court disagreed. It found that the plaintiff had, to his own detriment, relied on the doctor’s direct advice to him that surgery was not needed. The court overturned summary judgment and sent the case to trial.

Regardless of who’s paying your fees, you should assume that a standard physician-patient relationship exists and proceed accordingly any time you provide the patient with medical advice or other information about the state or progress of his health, especially if you are performing serial exams or evaluations. That’s the best way to protect both the patient’s health and your own legal interests.

Another issue is that, once you initiate treatment, a physician-patient relationship is automatically created and you must respect the patient’s confidentiality going forward. Occupational medicine specialist Greg Herndon discovered this the hard way when he treated laborer Alex Dienst for a job-incurred back injury.[7] Dienst was referred by the company nurse to Herndon, who was under contract with the employer, for treatment.

A company supervisor, noting that Dienst had appeared groggy, called the doctor and requested a drug screen, which Herndon performed with Dienst’s oral permission. When the urinalysis came back positive for marijuana, Dienst was fired.

Dienst then sued the doctor for breach of patient confidentiality. Dienst claimed that he was clearly impaired at the time Herndon requested the urine sample (although Dienst himself claimed that his impairment was from antihistamines), such that he could not have given informed consent for the test. Although a lower court dismissed the claim, an appellate court found that it would have been a violation of patient confidentiality for the doctor to communicate his findings to the employer without the patient’s permission. The higher court also observed that the patient had not signed an advance consent document that would permit the doctor to disclose any of his medical findings to the employer. Ruling that it should be left to a jury to decide whether Dienst had been too impaired to provide consent, the higher court reinstated the case.

Tests or procedures ordered by another doctor can also cause problems unless reasonable care is taken to make sure that the referring physician is made aware of the abnormal report or, failing that, the patient is contacted directly. This point is illustrated by the case in which radiologist Collin Jones evaluated a chest X-ray of nurse Edna Simms as part of her pre-employment tuberculosis screening by a managed care organization (MCO).[8] Jones was himself an independent contractor working with a third-party clinic that provided X-ray services to the MCO.

Jones wrote in his report that the X-ray showed a “small nodule overlying the right sixth rib” and a “patchy consolidated parenchymal pattern superimposing the right third rib anteriorly and interspace.” Jones forwarded his report to the clinic, which then forwarded the report to the MCO. The policy of the MCO was to inform the examinee within 72 hours of any adverse findings. For whatever reason, nurse Simms was not notified of Jones’ report. Approximately 10 months later, Simms was diagnosed with lung cancer.

Simms then sued Jones, the clinic, and the MCO alleging that their failure to inform her of the X-ray report negligently delayed her diagnosis. The MCO, however, had declared bankruptcy and the case against it was dismissed. Jones and the clinic applied for and received summary judgment on the argument that no physician-patient relationship existed and therefore they did not owe an independent duty to make sure that examinees were advised of their reports. Simms appealed, and the state supreme court ultimately determined that Jones did, in fact, owe a duty to make sure that the referring physician was made aware of any adverse findings or, if that physician could not be located, to contact the patient directly.

Also, be advised that just informing the other doctor’s staff of your findings may not be not enough. Consider the case in which the courts held that a radiologist did not discharge his duty by leaving a message with a clerk at another clinic that their patient had a previously undiagnosed wrist fracture.[9] The message did not get passed on to the patient’s regular doctor, and the patient suffered permanent loss of mobility in his wrist because of the delayed diagnosis. The radiologist was subsequently held liable for not informing the patient of his injuries in a timely manner.

To summarize, your best option when an independent medical examination reveals a significant or suspicious finding is to inform the examinee directly, making sure that he is aware of the potential gravity of the situation and the need for prompt follow-up. If you do choose to let another doctor carry out this duty, make sure that you talk directly with that physician and obtain his or her agreement to inform the patient and arrange appropriate follow-up. In either case, document the conversation carefully, making sure to record the time and the date of the exchange, and specify exactly what the other party agreed to do in follow-up.

The bottom line on limited duty of care owed during independent medical exams:

Following the AMA’s position on the matter, the courts recognize that the doctor conducting an independent medical examination owes the examinee a limited duty of care even in the absence of a physician-patient relationship. To honor your duty to the examinee and protect patient safety:

  • Be aware that you have a duty to inform the examinee of any untoward findings, and that only another physician who has been properly apprised of your findings and agrees to inform the patient in your stead can assume this duty.
  • Any contract with a third party in which you agree not to discuss your findings with the examinee is unethical and unenforceable.
  • Advising the examinee of an untoward finding and the need for follow-up with another doctor does not create a physician-patient relationship. However, such warnings must make clear the potential gravity of the situation and the need for prompt follow-up.
  • Providing the examinee with direct medical advice will generally create a physician-patient relationship, and providing treatment does so automatically. In such cases, you owe the examinee the same duty as any other patient, regardless of who’s paying your fee.
  • When a test or procedure ordered by another doctor results in a normal or abnormal finding, you should contact the referring doctor or an appropriate representative directly to explain your concerns. If the referring doctor cannot be located, you owe a duty to contact the examinee directly. As always, document all such communications.

Other Duties during Independent Medical Examinations

Beyond a limited duty of care, you also owe a duty to conduct your examination in a competent and professional manner so as not to cause undue risk or harm to the examinee’s person or civil rights.

You must respect examinee privacy by not sharing health-related information with anyone other than the entity that has the examinee’s signed permission to access such information. Even in communications with an authorized third party, you can only disclose those findings that are directly pertinent to your examination, plus the results and interpretations of any tests or evaluations that the examinee has consented to. Any findings that are incidental to your examination, especially those that might have been divulged by the examinee in confidence, will most likely be considered confidential. As such, revealing them to the third party constitutes an invasion of privacy and may lead to legal action.

That’s what happened when neurologist Brian Lister was hired by the employer of machinist Thomas Vila to evaluate Vila’s claims of disabling head and back pain resulting from a work-related injury.[10] At the conclusion of the examination, which involved inserting reusable metal electrodes into the examinee’s skin, Vila advised the nurse to be careful in handling and sterilizing the electrodes because he had tested positive for HIV.

The nurse informed Lister of this revelation, and Lister subsequently wrote in his report that Vila’s symptoms were more likely the result of AIDS than of physical injury. Vila’s claim was denied, and he sued the neurologist for invasion of privacy. The trial court dismissed the suit on the basis that Vila had voluntarily disclosed the information during an adversarial medical examination, and therefore had waived confidentiality within the context of his worker’s compensation claim.

Vila appealed, and the higher court considered the fact that the neurologist had not specifically inquired about or tested for HIV as a part of his evaluation. As such, Vila’s HIV status was not pertinent to the examination, and had been volunteered solely within the context of protecting someone else from becoming infected. The court did not consider this to be a waiver of confidentiality, and therefore reinstated the case against the neurologist.

Given that the entire point of a third-part examination is to collect information about the examinee for the benefit of someone else—information that the examinee may not want revealed—it’s a good idea to spell out your intentions in the examinee consent form. The benefit of doing this is shown by the case in which psychiatrist Devon Walker agreed to assess hotel worker Sean Barron at the behest of his employer.[11] Barron had a history of disputes with other hotel employees, including allegations of sexual harassment, and Walker was asked to assess the truthfulness of Barron’s denial of wrongdoing. Initially, Barron complied with the examination under protest. But when Barron refused to complete the full course of psychiatric exams scheduled, the hotel fired him.

Barron then sued Walker for invasion of privacy, alleging that the psychiatrist had subjected him to intrusive, improper, and harassing questions, including queries about his sex life and his parents’ sex life. In his defense, Walker argued that his line of questioning was professionally appropriate for someone accused of harassment.

Walker’s strongest defense, however, was the consent form he had Barron sign before beginning the examination. That form read, in part: “Although [the psychiatrist] is a doctor, we do not have a doctor/patient relationship. What we discuss in the assessment is not confidential or privileged as [it] would be in a therapeutic doctor/patient relationship…At some point, I will be reporting back to your employer.”

Having signed this statement, the court reasoned, Barron had no reasonable expectation that his discussions with the psychiatrist were carried out in confidence. The trial court dismissed the case, which was upheld on appeal.

Ex parte communications carry special legal hazards. Assume your patient has filed a worker’s compensation or other personal injury claim, and has signed a release authorizing you to provide records of his treatment to the company he filed the claim against. You carefully read the release and forward only the specified patient information. Then, as allowed under the provisions of the signed release, a representative of the company calls you to discuss your report.

When you pick up the phone, realize that you are in a precarious position. The legal term for this is an ex parte communication, which means that neither your patient nor his attorney will be present to monitor or challenge what is said. In order to protect your patient’s legal interests, the law limits such communications to a discussion of the contents of your medical report, a copy of which must also be made available to your patient.

You are allowed to explain or elaborate on your report with the third party representative, but you can be held liable if you discuss information not covered by your report, regardless of who brings it up. This is true even if the patient’s actions involve you in the perpetuation of a fraud against the third party.

In one notable case, FP Mark Clarkson treated laborer David Miller for injuries to his back and leg suffered from a fall at work.[12] Clarkson ordered his patient to stay home from work for a week, then report for another examination. Miller complained of the same symptoms at the subsequent visit and was ordered to stay home for another week, followed by a repeat exam. This sequence was repeated weekly, and Clarkson completed a worker’s compensation certification of Miller’s temporary total disability.

After two months, a representative of Miller’s employer went to Clarkson’s office and asked to meet with him about Miller. Clarkson agreed and was shown photos and videos of Miller digging a trench during the time he was supposedly incapable of such work. The FP then wrote a letter to worker’s compensation withdrawing his certification of Miller’s disability. Miller was subsequently fired from his job and his claim for disability benefits was denied.

Miller sued his employer for interfering in the physician-patient relation, and the FP for breach of physician-patient confidentiality. The defendants applied for summary judgment on several grounds, including the fact that Miller had signed a worker’s compensation form stating specifically, “I acknowledge…providing authorization for release of medical information by a physician to my employer or employer representative.” They also pointed to established legal precedents holding that physician-patient confidentiality is waived when the patient’s purpose in seeing the doctor is illegal, such as when the patient provides false statements to obtain drugs.

The state supreme court, asked to review the issues before trial, found that the consent form signed by the patient pertained only to the exchange of medical information and did not allow the doctor and employer’s representatives to conduct ex parte meetings for the purpose of “…persuad[ing] the treating physician to alter his diagnosis, course of treatment or recommendations.” Finding that the privacy of the physician-patient relationship was more important than the employer’s right to protect itself from fraud, the court denied summary judgment and ordered the case to trial.

The lesson here is not that clinic personnel should turn a blind eye toward fraud, but that they should insist that such matters be handled through formal legal channels in which everyone’s rights are protected. In the above case, for example, Clarkson took the word of the employer’s representative that the evidence presented him had been gathered during the period of alleged disability and that the person pictured was actually his patient. What if the evidence had been gathered before the accident, or the person appearing in the video was really someone else? To protect against such injustices, the law demands that the patient and his lawyer have the right to be present when such evidence is presented.

Before meeting with the employer’s representative, Clarkson should have contacted the patient and requested permission for the meeting. If the patient refused—which he most likely would have—it would be up to the employer to call for a formal worker’s compensation hearing. At that hearing, which would be open to all parties, the physician would have been asked to review the incriminating photos and video after his patient had been given the opportunity to contest their legitimacy. At that time, the doctor could have testified as to his belief that the patient was faking disability with little risk of future legal entanglements.

Any time a third party attempts to obtain or offer information about your patient that goes beyond a discussion of your medical report, refuse the request and contact your malpractice carrier for advice.

You must not injure the examinee, as shown by the case that began when orthopedist Arturo Arena was contracted by an oil company to evaluate employee Ann Gorton’s claim of work-related injuries.[13] During the examination, Gorton would later allege, she was negligently “strapped…into an apparatus which caused her body to be contorted and maneuvered in various damaging positions.” As a result, she claimed, she suffered a “total collapse and deterioration” of an earlier spinal fusion at L5, resulting in severe, permanent, and disabling injuries along with mental and physical pain and suffering.

Arena, while not contesting the cause or severity of the injuries, argued that he owed Gorton no duty arising from his examination. A lower court agreed and granted him summary judgment. An appellate court, however, reasoned that this ruling, if allowed to stand, would permit doctors to injure examinees with impunity simply because they had no duty otherwise. Following judicial precedents in other states, the appeals court overturned summary judgment and ordered the case to trial, holding that a “physician owes duty to examinee and may be liable for negligence or professional malpractice for injuries incurred during examination even in the absence of a physician-patient relationship.”

You owe a duty to the third party, irrespective of any duty owed to the examinee, to conduct your examination within the standard of care and to report your findings appropriately. This point is illustrated by the case that began when occupational medicine specialist Jerome Pointer performed a pre-employment physical examination of truck driver Morgan Frost on behalf of Barton Transport Company.[14]

At the time of his examination, Frost suffered chorioretinitis in both eyes, with 95 percent loss of vision in one eye and blurred vision in the other. He also suffered from, among other problems, osteoarthritis of the knees and chronic degenerative disc disease of the cervical and lumbar spine, severely limiting his range of motion. His overall physical condition was so bad that he had been declared 100 percent disabled five years earlier. Nonetheless, Pointer gave Frost a clean bill of health, stating that his vision, reflexes, and extremities were all normal. Based on this, Barton Transport hired Frost as a driver.

Two days after Frost was hired, he plowed a company truck into the rear end of a station wagon parked in the emergency lane of a highway, killing a child and severely injuring three others, along with their father. The accident happened at night, and Frost was unable to see the car until it was too late to avoid hitting it.

Barton Transport then sued Pointer, alleging that his negligent examination of Frost was the proximate cause of the tragedy. A lower court granted Pointer a directed verdict, stating that there was simply not enough evidence to lead to the conclusion that the faulty examination, which even Pointer conceded had been negligent, was the proximate cause of the accident. But the state’s supreme court disagreed, holding that the evidence was sufficient to support such a conclusion, and that the accident was a foreseeable consequence of the doctor’s failure to conduct a competent examination. The case was reinstated and ordered to trial.

The bottom line on other duties owed during independent medical exams:

Beyond the limited duty of care, you also owe the following duties during an independent medical examination:

  • You must respect the examinee’s privacy and not divulge to the third party any findings that are incidental to the purpose of your exam or that were provided to you in confidence. To avoid misunderstandings, it’s a good idea to have the examinee sign a consent form acknowledging and authorizing the types of information that you will be providing to the third party.
  • In communications with the third party requesting the exam, you may not discuss matters not included in your original report without the examinee’s permission. This is true even if it appears that the examinee is perpetuating a fraud against the third party. If the examinee refuses to grant such permission, the third party has a right to compel your testimony at a hearing, at which time you may speak freely.
  • You must not subject the examinee to undue risks or injury.
  • Irrespective of any duty owed the examinee, you owe the third party a duty to conduct the examination competently and to provide the third party with a professionally reliable report relevant to the purpose of the exam.

NOTE: the authors often receive requests for final disposition of the cases that are remanded back to the trial court after appeal.  In most cases, when the physician defendant loses an appeal, the parties thereafter enter into a confidential settlement agreement that legally prohibits both sides from discussing the case with others.  Even when the case is decided by jury trial, the outcome is not published by the courts unless an appeals court agrees to review the verdict.  While every reasonable attempt is made to learn of the final outcome of the cases presented, this information is usually not available.  However, the lessons to be learned from the case law decisions still stand, regardless of the final outcome of the cases themselves.

Also, the names of the parties in the cases have been changed to protect undue embarrassment to the involved parties.  If you want details on a case, review the cited case at a law library.

One final word: The information presented in article is for general educational purposes only and should never be construed as legal advice.  If you need legal advice on a specific risk management issue, always consult with your malpractice carrier or your own attorney.

[1] Council on Ethical and Judicial Affairs, American Medical Association, Opinion E-10.03 (AMA Opinion), Patient-Physician Relationship in the Contest of Work-Related and Independent Medical Examinations. Current Opinions, December, 1999.

[2] Rhodes v. Button, 764 A.2d 433 (N.J. 2001).

[3] White v. Southside Hospital, 721 N.Y.S.2d 678.

[4] Moore v. Preventive Medicine Medical Group, 223 Cal.Rptr. 859.

[5] Heller v. Peekskill Community Hospital, 603 N.Y.S.2d 548.

[6] Hickey v. Travelers Ins. Co., 558 N.Y.S.2d 554.

[7] Crocker v. Synpol, Inc. 732 S.W.2d 429.

[8] Stanley v. McCarver, 92 P.3d 849.

[9] Siggers v. Barlow, 906 F.2d 241.

[10] Vilaiak v. Newton, 277 Cal.Rptr. 354.

[11] Presented without citation in Zarin’s Medical Liability Alert (newsletter) 2007;15(10):10.

[12] Morris v. Consolidated Coal Co., 446 S.E.2d 648.

[13] Mero v. Sadoff, 37 Cal.Rptr.2d 769.

[14] Wharton Transport Corp. v. Bridges, 606 S.W.2d 521.

Tagged: Health Policy, IMEs, Legal Issues, Regulatory Issues, The Practice of Medicine Leave a Comment

March 17, 2014

A Clinical Story Worth Sharing

Most IMEs answer straight-forward questions on known issues. But there are those rare but important moments where we are reminded that things are not always as they seem, and that an examination can have extraordinary and unexpected value and impact on peoples’ lives. Allow me to share such a story.

Recently MCN conducted an IME on a 46-year-old woman who had back pain complaints in a workers’ compensation claim. The physicians who evaluated her found her to not be fixed and stable, and elected to order an MRI of the spine. It should be noted that the doctors felt that the findings they observed did not wholly fit with the injury claim but that they were significant. Typically an MRI would not be ordered for a low back pain complaint.

Five days after the evaluation she underwent the study. That same day MCN received a call from the radiologist who reviewed the film, calling our attention to unexpected findings of a mixed signal intensity mass involving the lower pole of the right kidney, approximately 4.5 by 4.4 centimeter. He noted that this may represent a renal cyst, but that a renal cell neoplasm could not be ruled out.

We informed the examining doctors who saw the claimant about these findings as well as the claims manager. As Medical Director, my priority at MCN changed in part from processing a report for her claim to doing right clinically by the claimant and ensuring that she was aware of these findings. I called her and told her that we had found something unexpected and explained to her the importance of prompt follow-up, and forwarded her the radiology report along with this email:

It was nice speaking to you this evening. As I mentioned, I am the Medical Director of MCN where you were seen for an IME on November 9, 2013 for your workplace injury. The report is in draft form at this point in time and when completed, will be sent to the department. I do note that the doctors who evaluated you did not regard you as fixed and stable and that you warrant either further treatment or evaluation.

As part of your evaluation, you underwent an MRI on November 14, 2013. The report is attached to this email.

As you can see, the radiologist reading this study noted an unusual mass that caused them to call our office, and it thus came to my attention. We will be letting the examining doctors know about this as well.

While I do not wish to alarm you, it is most important that you seek evaluation for this finding. It is possible that some of the symptoms you experience may be related to this rather than the injury. Regardless, it should be assessed to determine if it is of significance and warrants treatment.

I would recommend that you present these findings to your personal physician and work with them to investigate and follow up as appropriate.

I would appreciate any follow-up that you wish to offer and hope that the findings turn out to be insignificant and that you recover nicely from your injury.

Please let me know if you have any questions or if we can be of further assistance.

Thank you for your attention.

Brian L. Grant, MD

One week later I was surprised and touched by the following text:

Hi, this is (name withheld). I found out yesterday at the mass on my kidney is cancer. Will know more on Monday. Seeing oncologists and urologist. Thank you and please please please thank the two wonderful doctors that ordered the MRI and for taking my complaints seriously. Bless you all.

Several weeks later she underwent a partial nephrectomy at a large University medical center in the region. The subsequent weeks were rocky emotionally for her but in the end she was relieved to learn that she had a clear cell renal carcinoma and that the surgery was able to completely remove the tumor with all margins clear for carcinoma.

And by the way, her claim was also processed with an impairment rating relative to the back findings, and a settlement from the carrier.

My point in sharing this is that the work we do has impact, sometimes in ways we would never anticipate. In this case we identified a tumor causing back symptoms and took the necessary steps to help this patient get the right care in a timeframe that perhaps contributed to a great outcome. I am proud of all involved in this case and we all wish the claimant the best outcome.

Brian L. Grant, MD

Tagged: Clinical Issues, IMEs, Injury and Trauma, Workers' Compensation 1 Comment

October 8, 2013

Social Security Disability Fraud Revealed

Senator Tom Coburn of Oklahoma chaired a hearing of the Homeland Security & Governmental Affairs Committee on the topic of Disability Fraud. The hearing was revealing, as are these articles (CBS News/60 Minutes, ABAJournal, C-Span). Coburn, a physician himself, detailed one fraud scheme.

As he details the boilerplate employed by those named in the current scheme, including attorneys and physicians, one can’t help but wonder if those involved in the system were not aware of the abuse as it took place, only to ignore the sham claims that were being approved by the thousands.

Perhaps the tide is shifting against the tolerance for misuse of the system. Unclear in this matter is what will take place with the claimants who have received millions if not billions of dollars as a result of fraud.

Tagged: Cost Containment, Government Policy, Health Policy, IMEs, Legal Issues, Personal Injury, Regulatory Issues Leave a Comment

July 26, 2013

Outing a Problem with Our Industry – Once Again

A recent posting on Workers Comp Insider by  Lynch Ryan, a prominent Workers’ Compensation Defense firm, exposes shameful behavior on the part of a small but prolific minority of consultants and companies in our field. The posting speaks for itself. It also references the NY Times 2009 expose on problems in the Northeast and links to a plaintiff attorney blog that expands upon the issue.

MCNTalk posted the original NY Times articles and expanded upon ethics and standards in this posting from March 2011.

We were naively hopeful back then that exposure of such practices would lead to their end. We were apparently wrong. The company cited in the article has since renamed itself and continues with similar practices. Certain physicians continue to behave in entirely unacceptable manners, with impossibly brief examinations, use of boiler plate, and other questionable practices.

The end result is a regional ecosystem that is tainted by cynicism and scandal. Those who behave honestly and attempt to provide an ethical product are at a disadvantage when medical bucket- shops operate and charge unrealistically low prices for products that do not meet basic medical and legal standards. There are at least several large carriers whose regional offices have grown accustomed to using these entities and paying fees that ethical companies and physicians can’t match.

One should not have to rely upon external forces to do the right thing, but this situation suggests that expecting integrity for its own sake is not always realistic. We continue to hold out hope that those who buy these services become aware of what they are buying, if they are not already in the know, and that these questionable practices no longer have a market. We also hope that continuing to shine a light on this issue by multiple means, including the regulatory and legal arenas, will bring these abuses to a halt.

We at MCN are not going to just go along or get along when we see behaviors in our backyard and our industry that we can neither  defend nor tolerate. We hold ourselves to a higher standard and will not stop until others in our industry stop dishonoring themselves, the medical profession, our industry clients, and claimants. We ask our clients to support us in this industry challenge and ask tough questions of those you are doing business with.

Tagged: Health Policy, IMEs, Legal Issues Leave a Comment

February 1, 2013

Occupational Carpal Tunnel Syndrome & Potential Cost Savings

By Scott Smith, MD

carpal-tunnel1The cost of treating occupational carpal tunnel syndrome is three to five times greater than and the results considerably less successful than that of non-occupational carpal tunnel syndrome, though the pathology is the same in both.

The diminished success rate is a complex issue, not reviewed here.  However, the excessive costs can be reduced without affecting quality of care through a number of measures reviewed briefly below and confirmed by evidence-based medicine.

First, is reducing the number of claims accepted by more narrowly and accurately defining criteria for the allowance of carpal tunnel syndrome as an occupational disease.

The Washington Department of Labor & Industries Medical Examiner’s Handbook criteria are that it “must arise naturally and proximately out of employment” whereas the Washington Department of L&I Medical Guidelines for the Treatment of Carpal Tunnel Syndrome (2008) merely requires that the occupation “constributed to the development or worsening of the condition” – a much broader and vague definition in which almost any occupation could be interpreted contributory to carpal tunnel syndrome.

Better, in my estimation, would first, like Kansas, use the term “prevailing factor” rather than “contributory factor.”  Second, to use systematic literature reviews that list the occupations in which the risk of carpal tunnel syndrome is at least doubled compared with the general population.

Secondly, whereas the Washington State Medical Treatment Guidelines require electrodiagnostic studies when carpal tunnel release is being considered, they are in classical practice often not needed for diagnosis especially when the signs and symptoms are classic, in which case surgical results are still excellent.  Further, electrodiagnostic studies have only a limited role in predicting successful outcome of carpal tunnel release and hence do not fulfill this more important goal.

The American Academy of Orthopedic Surgeons’ (whose members do the majority of carpal tunnel releases) Clinical Practice Guidelines summary for carpal tunnel syndrome concurs with this conclusion, but add it in combination with history and physical examination, may be more predictive of successful results.  It is unclear, however, whether occupational carpal tunnel syndrome was included.

There are other reasons to decrease the use of electrodiagnostic studies.  For example, postoperative use to determine recurrence or degree of symptoms is not helpful because there is poor correlation with those symptoms and the severity or change in the electrodiagnostic studies.

Third, ergonomic evaluations and recommendations seem to be overused.  Ergonomic modifications of the workplace at least intuitively, given the association of carpal tunnel syndrome with various activities involving repetition, vibration, force, and awkward postures, should diminish the incidence of carpal tunnel syndrome in the workplace and reduce its symptoms. Hence, the Washington L & I Medical Treatment Guidelines recommend “ergonomic assessment of work site within two weeks of the first healthcare visit for people with carpal tunnel syndrome to assist with work modification.” Nonetheless in a series of 24 studies on the subject in the year 2000, none of them conclusively demonstrated that the interventions would result in the prevention of carpal tunnel syndrome or its amelioration in a working population.  They do not seem therefore to be a cost-effective intervention.

Lastly and for multiple reasons, return to work issues are always very important in a workman’s compensation setting and an important concept because in genera, return to work is actually in the best interest of the worker as well as the employer. 

Medical Disability Guidelines have recommended optimum return to work durations after carpal tunnel release that range from two to eight weeks depending on the work classification, whereas other “optimum recommendations” are from 0 to 4 weeks, demonstrating considerable variation.  Considering the relatively simple nature of carpal tunnel release, return to work for sedentary and light job classifications should actually be less than one week.  Longer periods would reflect worker desires and pain tolerance rather than any risk of harm.

In association with return to work are Functional Capacity Evaluations (FCEs), though less commonly done for carpal tunnel releases than other conditions, their purpose is to improve return to work by determining what limitations, if any, are required physically. In fact, for reasons beyond the scope of this brief review, that is unfortunately not the case and can even diminish the chances of return to work compared with giving no restrictions.

Summary: The above are methods that without altering quality of care, could potentially lead to significant cost savings in diagnosis and treatment of carpal tunnel syndrome in the occupational setting.  According to an August 2012 Washington Department of Labor and Industries news communication, L & I is currently contracting with an independent researcher to study occupational disease claims in Washington.  Hopefully some of the cost savings noted above would be considered.

 D. Scott Smith has been an Orthopedic Surgeon who has worked on MCN’s provider panel for 12 years and has spoken at CEU events sponsored by MCN. To learn more, please email MCNTalk@mcn.com.

47.608945-122.332015

Tagged: carpal tunnel syndrome, Cost Containment, disability, excessive costs, IMEs, Injury and Trauma, occupational health, Workers' Compensation, Workplace Situations Leave a Comment

December 8, 2011

MCN Promotes Industry-Wide Examination Standards

by Brian L. Grant, MD

We at MCN speak about quality in examination and review services and hear similar speech from others including competitors. The term “quality” is but a homily or empty rhetoric unless it is defined and clarified. We also believe that some may have been led astray when they allow quality to be defined along standards that lose sight of the inherent values of the medical profession. We believe that adherence to quality standards is neither negotiable nor fluid or subject to market forces. From time to time we observe within our company or learn from other quarters certain practices that we can’t endorse and ought not be endorsed or practiced by others. By raising the matter publicly we call attention to standards that should be expected by clients who order review services, by doctors who perform them, and by companies that facilitate them.

The below memo was sent to MCN consultants. We share them with you and invite you to pass them on. Or if readers have additional standards or take issue with any we have raised, we would enjoy hearing from you:

December 6, 2011

To: MCN Consultants

From: Mark Doyne MD and Brian Grant MD, Medical Directors

Regarding: Examination conduct, standards and physician demeanor

As medical directors for MCN, we review complaints that periodically arrive from claimants regarding their examinations. Every one of these is reviewed individually and each physician is given the opportunity to respond. We are passionate about the integrity of MCN examinations and expect that all MCN consultants share our values and practice accordingly. Given the nature of our work, a complaint should be reviewed in the context of the nature of the issues raised, including the possibility of there being other motivations for a given complaint among other factors. We do not take complaints at face value at all times. We review the specifics and may conclude that a complaint may lack merit. Sometimes we may choose to investigate with a call to the claimant and review the consultant’s response to the complaint. Other times we have chosen to briefly survey other claimants who have been evaluated by the consultant via phone calls to them and an audit of the corresponding reports.

Certain types of problems, when representing a pattern, will and have resulted in termination of a consulting relationship with the company for specific consultants. We believe that adherence to appropriate standards should be inherent in the profession and are obvious requirements to perform quality reports. As such, they may be beyond the scope of MCN or others to teach, and when basic standards are not adhered to, this is a serious matter.

We expect consultants performing medical reviews, whether for MCN or others, clients requesting such examinations, and competing companies to adhere to basic standards of conduct and practice.

Some of the points below have been conveyed in past memos. We are restating them as a reminder, and for the benefit of new consultants. We call upon the industry, including clients, physician consultants and MCN’s competitors, to enforce adherence to these standards, embracing them in intent and practice. We also welcome your comments and additional ideas.

Our standards (as expected of all who perform medical reviews) include but are not limited to the following:

Sufficient Time Must Be Spent with Claimants. We expect that the consultant devote sufficient time for a thorough review of records, history and physical or mental status assessment of the claimant. It is NOT appropriate to book exams in increments of less than thirty minutes. We have heard stories of companies in certain regions of the country where four to six or more exams scheduled per hour are not uncommon. Some consultants find it of benefit to review the records in the presence of the claimant. If time has been spent away from the claimant reviewing the records, however, it might be a good idea to share this fact and show those records to the claimant. Actual face time with claimants should be sufficient to perform an appropriate history and examination without creating a perception by the claimant of being rushed. It is impossible to perform a thorough history and physical of a typical injury claim in less than thirty minutes and often more time is required.

Reports Must Be of Sufficient Length. A report should be several pages or more in length, have sufficient depth to answer the questions of the client, and reflect a thoughtful, individual review of the specific case. There should be documentation of what has been reviewed. We remind you that it is not necessary to extensively quote records that have been reviewed. Some consultants issue reviews that are unnecessarily long. It should generally suffice to state the nature of the record, date, person who generated it, and a brief reference to the conclusions. The goal is to be certain that you have reviewed the document and considered it in your conclusions. If need be, one can refer to the original document at a later date.

Each Case Must Be Evaluated on Its Individual Merit with Every Examination a Unique Event. Other than a preliminary disclosure paragraph used at times, MCN does not employ any standard language in reports. We expect that consultants likewise will individualize each report in their own words. Held to the light, no two reports should ever appear the same or close to the same. Clinical boilerplate is not permitted for MCN examinations. Normal findings, if conveyed numerically, should reflect normal range and not a standard value.

Report Findings Must Be Objective and Evidence-Based. Our clients want quality, objective reports, regardless of claim impact. They want reports that are based upon data, not merely a claimant’s self-report. They use IMEs and medical reviews because they want incisive and critical medical thinking. If they wanted a report to repeat the claims of the claimant in the absence of data, they would have no need to spend the time and resources to ask for an IME and would merely accept what the claimant says. The reader of the report (more often than not a non-clinical individual) should be able to understand the reasoning behind the conclusions.

 Consultants Must “Stay in the Box.”  This means answering each question you are asked, not answering questions you are not asked, and staying within your area of clinical expertise. These are simple concepts, but too often not honored.

Reports Must Be Issued in a Timely Manner. A good examination ceases to be good if the consultant is late on initial report submission, signatures, clarifications, and other actions that delay report issuance. Our clients are often working under time constraints. Delays rarely add value and quality may be diminished with the passage of time as specific details can fade. We rely upon consultants being timely to meet our mutual commitments.

Claimants Must Be Shown Respect During all Interactions. Remember that some claimants are nervous, apprehensive, and often unsophisticated when they report for an examination. They deserve a response to questions and an explanation of procedures as well as appropriate respect for modesty and personal boundaries. Curtness, over-familiarity, and criticism of the claimant or their treating physicians are all to be avoided. Demonstrate respect for claimants as you would want your own friends or family members to be shown respect if they were to be sent for an examination. And write a report that you would respect if issued by a colleague.

Treatment Is Never Offered During an Independent Medical Evaluation. Never offer treatment or comment on current or past treating doctors: Please remember that your credibility depends on being regarded as neutral, objective, and not vested clinically. From time to time a claimant may request that a reviewing doctor assume treatment, and there have been situations when a reviewing doctor has offered his/her own services or even issued a prescription. Offering any sort of treatment, however, should never occur. If there is an urgent medical matter observed during an evaluation, stabilization and referral to an appropriate physician or emergency facility should be undertaken.

Testing Should Only Be Performed as Necessary. Additional diagnostic testing should be only performed when necessary to answer questions posed to the examiner.  In many cases testing must be authorized by MCN or the client. In our experience the need for additional testing is relatively infrequent because numerous diagnostic tests have typically been performed prior to the IME, with the results readily available in the medical records.

We are proud of our work at MCN. We have been in the business of performing medical judgment services for almost twenty-seven years and strongly believe in the value of our services to society and the integrity of the company and our consultants. We call upon all involved in requesting and providing such services to adapt and enforce standards that reflect the best of medicine and respect for the dignity of claimants.

Thank you for your support and quality consultations. If you have any questions or comments, feel free to contact Brian Grant at bgrant@mcn.com or 206.447.3449. Mark Doyne may be reached at mdoyne@mcn.com or by phone at 214.762.0784.

47.608945-122.332015

Tagged: Clinical Issues, Health Policy, IMEs, MCN News and Events, Workers' Compensation Leave a Comment

November 14, 2011

What Happens in Vegas

Sometimes what happens in Vegas doesn’t necessarily stay in Vegas. Members of Medical Consultants Network’s executive and sales teams just returned from the 21st annual National Workers’ Compensation and Disability Conference and Expo in Las Vegas, NV.

The conference is always an excellent opportunity to meet with clients in person, catch up with colleagues, and attend useful seminars as noted in workers’ compensation industry blog “Managed Care Matters.” We are pleased to have had the chance to learn more about how we can better serve our clients. And none of us minded leaving the Seattle fall (rainy) weather for a few days in the desert.

47.608945-122.332015

Tagged: IMEs, MCN News and Events, Workers' Compensation Leave a Comment

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