Although all physicians are licensed and trained in medical treatment, only a limited number have the expertise and know-how to perform an IME resulting in a medico-legal report that helps resolve claim disputes. Claims professionals can waste time trying to identify the right IME expert and still not end up with a quality, objective report. As a result, companies specializing in coordinating IMEs and providing quality oversight have evolved to assist in this effort.

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

• Initiate requests early. Once a claim is on a certain course, it’s difficult to make a drastic change in direction. We’ve seen situations in which claimants have received WC benefits for years on claims that were never properly evaluated and should not have been medically accepted in the first place. When causality is in question, a pre-existing condition is suspected or treatment begins to deviate from normal standards of care, an early IME can clarify issues upfront to help with claims decisions.
• Provide purpose and background. To obtain a useful result, it’s imperative to provide examining physicians with clear objectives and any specific questions that must be addressed in the final report. Is the exam to determine whether further medical care is needed, the level of permanent disability or other concerns? Is an impairment rating needed? It’s also helpful to limit questions to keep the objective in focus. Additionally, the physician should receive all relevant background documents, including a complete medical record, test results, job descriptions and claimant statements, well in advance of the exam.

Evolution of the IME industry

The WC industry has at times been suspicious of IMEs, believing results can be swayed to either dispute or support one’s case. At other times, IMEs have been viewed to waste time and resources. How can the industry obtain clear, objective medical evidence to assist in claim decisions?

This demand for quality IMEs has given rise to a service industry aimed at connecting the best, most qualified physicians to organizations requesting these exams and to claimants who must undergo the evaluations. Although the basic function of the IME has remained the same, the nature of the industry has evolved to meet a greater demand for quality and objectivity.

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

Consequently, WC insurers have moved from using many IME companies to establishing a preferred list of best-in-class IME companies with extensive geographic reach, a breadth of medical experts, clinical coordination, quality processes, efficient workflows and advanced technology platforms. Consolidation has enabled sophisticated IME companies to emerge that have structured their enterprises to provide the following benefits on a national basis:

• Quality providers. An IME company has relationships with a broad pool of medical experts. It evaluates and credentials physicians to make sure that they’re skilled at performing IMEs; do not have a sanction against their license, and have an active treating practice. The company has fostered relationships with providers, so it is familiar with their areas of specialty, board certifications and expertise on body parts, such as orthopedic surgeons who are specialized in hands versus knees. As a result, the IME company can promptly schedule an appointment and obtain a quick response.
• Clinical coordination. The IME company ensures that the exam addresses all pertinent clinical issues. Trained clinical coordinators organize medical records, highlight critical pieces of a file and identify the items that specifically should be reviewed and considered by the examining physician. For example, if the purpose of the IME is to assess causality, the coordinator ensures that appropriate diagnostic tests and medical reports are available and complete.
• Quality assurance. IME reports must be well written. The medical opinion is solely that of the examining physician; however, the IME company will review reports to ensure a concise, accurate and clear medical opinion that addresses all the issues at hand and sends any questions back for the provider to address The final IME report is vetted through a clinically focused process to provide a quality end result.
• Jurisdictional expertise. The IME company has in-depth knowledge of various jurisdictional requirements, such as when, why and how often IMEs can be requested. Each jurisdiction may use different evaluation guidelines, such as differing versions of the AMA Guides to Disability and Permanent Impairment, and may require different language and notifications. If state rules are not followed, for example, if the claimant is not given sufficient advance notice, an IME may be disallowed.
• Efficiencies. A sophisticated IME company has 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.
• Accreditation. As the bar for service continues to rise, sophisticated IMEs have obtained external accreditation. Through organizations such as URAC, an IME company validates its use of best practices regarding data security, quality business processes and HIPAA standards. For insurers looking to create a short list of IME vendors, URAC accreditation offers a stamp of approval that the IME company meets high quality standards.
• Infrastructure. An IME company should make strategic investments in data security and systems to better manage the IME process. Best practices include the use of secure portals for exam scheduling and efficiently transferring records, documents and reports for the IME physician to review.

WC industry consolidation, changing jurisdictional requirements and an ongoing demand for quality, impartial IMEs continues to drive change. The most successful IME companies continue to adapt to meet these industry needs.

To ensure a quality process, insurance companies should choose IME vendors carefully. Strategic initiatives have shifted the perspective of IME companies to trusted providers of medical opinions that guide the direction of claims and get injured workers the care they need to recover and return to work.

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