Nothing is more exasperating than to have an Independent Medical Examination challenged or disregarded in a claim where a medical controversy exists. These examinations can cost thousands of dollars for the examination visit and several more thousand dollars if the doctor testifies.
Challenges occur due to timeliness, improper foundation of information, improper doctor choice for the examination, lack of testing by the examining doctor, improper direction or no direction by the adjuster or medical manager for necessary results to meet objective of the controversy and the local state workers compensation law.
Many jurisdictions may limit the number of independent medical examinations. Others make the appointment process and notices to claimant cumbersome. This allows for delayed appointments.
Step One Pre-Determine:
Every injury has some normal time frame for medical recovery. As soon as the injury occurs it is essential to research with medical professionals (Doctors, Nurses, Medical Managers, and Or Nurse Practitioners) to expected normal recovery. If this is not feasible the minimum would be to use medical reference materials. The internet has many such web sites.
Once an expected recovery time is established the claim needs to be placed on diary for a medical study at the half way recovery point. Review current treatment, and status. Is the treatment in keeping with medical accepted practice? What are current symptoms? Is the claimant compliant with treatment needs? Has there been any underlying pathology discovered? Are treatment dates and follow up appointment reasonable and in keeping with proper medical practice? Should a medical case manager be assigned or review the process?
If the claim adjuster or employer is not sufficiently knowledgeable for this review, it should be done by a medical management professional.
Any hint of deviation requires immediate action to determine appropriate considerations for future modifications.
Step Two Properly Prepare:
Always chose the proper doctor for the Independent Medical Examination or Consultation. An Orthopedic Specialist should not review an eye case. Silly as it seems such situations can occur if there is a shortage of good Independent Medical Examiners. It is best if the Specialist is Board Certified.
Set appropriate reserve funds to cover the examination costs, tests, studies, and report preparation. Be prepared to cover costs the claimant may incur. These could include transportation, hotel and meal cost.
The adjuster, employer, or medical manager, need to prepare a complete package for the examination doctor.
The package must include:
- A complete history as to how the injury occurred.
- Copies of all medical reports, examinations, treatments, x-rays, drugs being used, current course of treatment by attending medical providers, and any information from the employer as to the employee’s health background, job performance, job attitudes and any other information that could be of value for the examiner to consider. (Be careful to observe proper protocols for using information and how it is used in the examiner’s reporting. Telephone discussions should be used prior to written documentation.
- A thoroughly complete job description. Include requirements for training, education, experience, physical demands, safety equipment, fellow employee interaction, hours to work, security needs, as well as any other aspects of the job operation.
- Discuss with the examining doctor any needs or other items that will help in the exam or evaluation report. Use the Examiner’s judgment as to the examination timing for best results. Discuss all objectives to be met by the exam and the report. Have the examining doctor provide physical functional capacities that the employer might use for light duty work until full recovery.
- Obtain a list of items from the defense attorney for needs to address. Telephone before documenting in writing.
- Put all appropriate items (from paragraphs: 3, 4, and 5 above) in a full written letter to the Doctor. Add any special or other need you want the doctor to address in the report.
- As soon as the examination date, time, and place is established send the claimant necessary notice in writing. Send two copies one regular mail and the second registered mail requiring a signature. Copy claimant and defense counsel where necessary.
- If claimant has counsel who will want to attend the examination it may be necessary to have a medical case manager in attendance as well. This would probably best be handled by defense counsel.
It will likely be necessary for the claimant and counsel to have copies of the examiner’s report. Have defense counsel review it before release and have appropriate corrections made. If the attending doctor has any objections, advise the examining doctor at once for response.
Be certain the latest items for both examining and attending doctors is current at the time of any hearing or testimony.
These are just the basics for a successful Independent Medical Examination. As always, it is best to be guided by defense counsel on investigations, reports and handling to obtain successful judicial results.
Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. He is an expert in employer communication systems and helps employers reduce their workers comp costs by 20% to 50%. He resides in the Boston area and works as a Qualified Loss Management Program provider working with high experience modification factor companies in the Massachusetts State Risk Pool. He is co-author of the #1 selling book on cost containment, Your Ultimate Guide To Mastering Workers Comp Costs www.reduceyourworkerscomp.com. Contact: email@example.com.
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.