The work of independent medical examiners can directly affect what you pay for a claim. Their findings may help determine whether an injury or illness is indeed work-related, or the extent of a permanent disability. Here are some pointers for working with independent medical examiners.
Either an employer or employee (or their representatives) can request an independent medical exam to provide a second opinion when a dispute about the nature, extent or cause of a work-related injury exists. Terminology varies by jurisdiction — some states call them independent medical evaluators or qualified medical evaluators. Regardless, the practitioner cannot be the claimant’s treating physician.
If your workers’ compensation insurer or administrator disagrees with the diagnosis or treatment plan of the claimant’s treating physician, it will likely request an independent medical exam. The process starts with selecting the right healthcare professional for the exam.
Your claims manager will consider:
• His/her specialty. Is it appropriate to the nature of the claim? For example, you would use an oncologist to examine a plant worker claiming her cancer was caused by exposure to chemicals in the workplace, while an orthopedic surgeon would be better suited to examine a nurse with a back injury claim.
• Board certification. Is the examiner board certified in the appropriate specialty?
• Experience. Does the examiner have experience in evaluating the condition, and familiarity with the state’s workers’ compensation system?
When requesting the exam, your claims adjustor or administrator should outline the concerns with the claim and provide the IME with a list of medical questions the exam should answer. The examiner will review the patient’s medical history, employment history and any reports from occupational safety experts. He/she may also need information on the individual’s nonoccupational activities to determine whether the injury or illness has causes outside the workplace.
When selecting an IME, the adjuster should also consider how claims are decided in your state. In some states, a workers’ compensation board or commission hearing a case on the extent of a permanent partial disability might split the difference between the opinion of the treating physician and the employer’s or insurer’s physician. That would make hiring a conservative IME advantageous. In other cases, workers’ compensation boards or commissions might discount the opinion of an overly conservative IME hired by an insurer or employer as biased, so your adjuster will want an IME with a reputation as objective.
Some states, such as California, require the employee/employer (or its insurer) to agree on one qualified medical examiner. Some allow the employer or insurer to order as many IMEs as it’s willing to pay for, while other states limit the employer to using only one IME during the claim process.
The American Medical Association cautions physicians that, “In an IME examination, there is usually only a one-time opportunity for examination. Therefore, the IME needs to provide a complete, comprehensive and objective description of the examinee’s condition at that time, in the context of prior health, physical and vocational capabilities, and social functioning. In contrast, the treating physician’s evaluations are based on multiple, shorter encounters over the course of time.
“Unlike the medical consultation that ends only with treatment recommendations, the IME is broader in scope. Often, the IME will answer specific questions posed by the referring source. Referring sources include insurers, attorneys and others involved in the management of workers’ compensation, personal injury, disability cases, and other similar issues.”
For more information on the workers’ compensation claims process, please contact the Insurance professionals of EPIC’s CRA ProRental™ Insurance Program. Call us at: 800.234.6363 or email us at prorental@epicbrokers.com. We can also provide you safety suggestions that can help prevent claims from occurring.