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January 30, 2015

IME: Success or Fishing Expedition?

Summary:

Independent medical exams are often outsourced, cutting out of the process the one stakeholder that knows the worker best: the employer.

Photo Courtesy of Annie Sullivan

Independent medical exams (IMEs) are widely used throughout the workers’ compensation insurance industry. However, as with any tool, you generally need a good carpenter or mechanic to get the best results. Because of the time required to arrange these medicolegal exams and because of the complexities of determining causation, pre-existing conditions, degree of impairment, etc., most insurance companies and third-party administrators (TPAs) outsource this function, which generates findings that can be used in the formal claims adjudication process.

The problem with outsourcing IMEs is that it typically removes from the process the only stakeholder who actually knows the injured worker: the employer.

The employer can make better decisions about whether to request IMEs — which are very expensive — by looking for red flags that, in many cases, only the employer could know about.

The most basic reason is if there is a legitimate question as to whether an injury or illness was caused by a work-related accident or industrial exposure. Red flags that might indicate the need for an IME include: The accident/injury wasn’t witnessed by other employees; reports of how the injury occurred are vague; or the injury was not promptly reported. Other triggers that only the employer would know include: a history of disciplinary, attendance or other HR issues; prior work history and the possibility that the employee is working a second job; or participation in sporting and recreational activities outside the workplace.

Other flags could be: Healthcare providers indicate that the employee may not be able to return to work, based on subjective complaints, or have proposed treating plans that are open-ended, with no clear-cut goals.

Other key issues that should be identified early in the claims process are: pre-existing conditions; any unauthorized medical treatment; any treatment by known “provider mills”; all litigated or potentially litigated claims; any potential subrogation opportunities; any doctor shopping; prescriptions for opioids; recommendations for elective surgery, such as on the back or for carpal tunnel issues; and any plain, old-fashioned tips from other employees.

IME providers often miss three fundamental questions: Can this injury or illness be caused by the workplace? Under what circumstances? Did these circumstances exist in this case?

Medical providers performing IMEs often make decisions in a vacuum, with little, if any, input from the employer. Leading medical experts who routinely perform IMEs state they are often “flying blind” and would have conducted a whole different physical exam or diagnostic testing if they only had more information. They tell me that they often have no idea why an IME has been scheduled. Miscommunication is common, and prior medical reports are often delayed or even lost.

IMEs should be conducted within a well-planned strategy at both the local level and the corporate level, between an employer and its insurer or TPA. The success or failure depends on active involvement and strong communications by all involved, including employers, IME providers, injured workers and insurance carriers and claims administrators.

As noted in previous articles, employers may consider using an OSHA-sanctioned “contemporaneous” medical exam – conducted at the moment of injury/illness notification but done outside the workers’ compensation system. Employers may consider this approach when they suspect a difficult or potentially litigated claim in states where they have little control over the choice of medical provider or face other jurisdictional or claim-specific challenges.

Employers, whether they are fully insured or self-insured, should ask detailed questions about how IMEs are handled on their behalf. Most insurers and TPAs outsource some, if not all, of the process of scheduling and arranging IMEs. There are dozens of questions I would ask about IME panel selection and quality assurance, including; credentialing, board certification, training, continuous education, experience, expertise, reputation, affiliation with university-based teaching hospitals or sports teams, along with knowledge and utilization of AMA impairment guidelines, evidence-based treatment protocols and application of disability guidelines from state workers’ comp, the Americans with Disabilities Act  (ADA) and others.

The only true stakeholder in what can be a very expensive, time-consuming and frustrating process to obtain quality IMEs is the employer. It is the employer that should be asking about “other” workers’ compensation costs and whether IMEs, which often include “hidden” costs, are actually having a positive outcome in successfully denying, closing or settling difficult and contentious workers compensation claims.

The 80/20 rules applies in both workers’ compensation and healthcare — 20% of claims will generate 80% of the costs. Employers need to have strategies in place both early and often to help confirm the relationship between reported injuries and illnesses and the workplace.

The employer’s ability to obtain credible and authoritative medical opinions is key to containing workers’ compensation costs from medical, indemnity (lost-wage replacement), permanent disability awards and administrative, legal and other fees.

Employers need to take a much more active role in ensuring high-quality healthcare while addressing waste, fraud and abuse in the system. Employers should avoid fishing expeditions but rather use these expensive tools wisely and put them in expert hands. If you are going fishing, make sure you have the right bait, deck hand and captain.

IMEs can be a great tool or waste of time and money. It’s more up to you than you think.

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About the Author

Dan Miller is president of Daniel R. Miller, MPH Consulting. He specializes in healthcare-cost containment, absence-management best practices (STD, LTD, FMLA and workers’ comp), integrated disability management and workers’ compensation managed care.

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