An independent medical examination (IME) should be completed when an employee’s recovery from an injury takes longer than normal, or when the employee is released from medical care, but receives a higher than expected disability rating by the treating physician. The IME documents the employee’s medical condition. An IME also provides the insurance company or employer with an independent verification as to whether the employee’s medical condition is or is not related to an on-the-job injury.
While most treating physicians are honest and reputable doctors, some treating physicians rely on referrals from plaintiff attorneys for the bulk of their business. These doctors have a tendency to overstate the employee’s disability and permanency level. They know the attorneys who provide them with patients use their medical evaluations to obtain the highest possible settlement for their clients. Therefore, the independent medical examination documenting the medical status of the employee is essential to the fair settlement of the workers comp claim.
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If the employee has more than one aspect of his/her health in question, more than one IME is necessary. For instance, to evaluate properly the employees workers comp claim, it may be necessary to have IMEs done by an orthopedic surgeon, a neurologist and a physical rehabilitation specialist. Most states limit the number of IMEs to one, two or three in each area of medicine. While a few states allow the insurer as many IMEs as they want, the cost of an IME can quickly add to the overall claim cost. Therefore, use IMEs when needed, but do not abuse the process.
An IME should be performed by a doctor who specializes in the field of medicine routinely treating the type of injury the employee has incurred. The IME doctor should not have been previously involved in the employee’s medical care either for the injury in question or for any other medical care. An IME does not create a doctor-patient relationship.
The purpose of an IME in a workers compensation claim is to determine the cause of injury and the extent of the disability from the injury. If the treating physician has not placed the employee at maximum medical improvement (MMI), the IME can be utilized to determine what further treatment the employee needs.
By obtaining an IME, the insurer is better able to make fair decisions on how to handle the claim. The IME provides the workers comp adjuster with the necessary information to discontinue medical treatment, to continue medical treatment, to change medical treatment, and to determine the appropriate permanent partial disability benefit or permanent total disability benefit.
In most states the workers comp adjuster selects the IME doctor. In a few states the adjuster must petition the Workers Compensation Board to have the employee seen by an IME doctor. In some states the workers comp board selects the IME doctor. Whether the doctor is adjuster selected or workers comp board selected, it is imperative the doctor be a specialist in the field of medicine that involves the injury. The proper selection of the doctor results in high quality exams both accurate and medically sound.
To insure the IME is accurate, the adjuster or the nurse case manager assigned to the claim, provides the IME doctor with all the employee’s medical records and diagnostic tests results (x-rays, CT scans, MRI reports, EMG studies, etc.). The information needs to be provided to the IME doctor well in advance of the employee’s appointment to allow the doctor time to review properly the medical history of the employee. Also, the adjuster or nurse case manager also provides the IME doctor with a detailed job description obtained from the employer – the IME doctor should not have to rely on the employee’s description of his/her work (which could overstate the physical demands of the job).
The IME doctor in addition to being provided the medical records, diagnostic test and job description, is informed of the reason the adjuster is requesting the examination — whether it is to establish what further medical care is needed, the level of permanent disability or other concern. By understanding why they are performing the IME, the doctor can then focus on answering the question(s) or concerns of the adjuster and/or the employer.
When the employee is represented by an attorney, the IME is normally set by agreement between the parties. If the employee’s attorney is uncooperative about having an IME it is usually a sign the employee’s attorney questions or doubt’s the veracity of the claim or the extent of the injury. When the employee or the employee’s attorney refuses an IME, an immediate petition to compel the IME is filed with the workers comp board.
During the IME the doctor conducts an interview of the employee, performs the appropriate medical examination, observe the employee’s general appearance, the employee’s gait, how the employee stands, whether or not the employee has any difficulty climbing onto the examination table, whether or not the employee shows any signs of distress and the employee’s weight. The doctor evaluates the employee’s subjective symptoms and determines if they are consistent with the manifestations of the injury claimed. The IME doctor looks for any signs of exaggeration or deception by the employee and will include in the IME report if the employee is intentionally exaggerating his/her symptoms or if s/he feels the employee is malingering.
Also during the IME the doctor performs various test to verify the symptoms alleged by the employee conform to the normal symptoms for the injury claimed. The doctor questions the employee about his/her ailment(s), the treatment the employee has had for the injury, whether or not the employee had a prior injury or an injury subsequent to the workers comp injury and discusses any underlying pathologies to the injury. The IME doctor determines if the employee smokes, drinks, uses illicit drugs or has other health or lifestyle issues that will impact the employee’s ability to recover from the injury or the employee’s level of permanent disability.
The independent medical examination should be used by the insurer or the employer to document the medical status of the employee at that moment in time. The information obtained from the IME is used either to provide the employee with the full medical care needed, or to determine the employee’s level of disability, or both
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact: RShafer@ReduceYourWorkersComp.com.
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
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I just met with an attorney who said that in his experience IME’s deny more than 95% the claims they review. I just had an IME deny 2 different claims that had bee previously approved by 5 separate doctors (2 hip and 3 back). So why does someone that works for the insurance company have so much power. I know there is an appeals process but my state strongly represents you obtain legal representation. So much for a fair and balanced system.
On the contrary of this report, IME are the ones who work for the insurance company to give a dishonest report in order to help the insurance company denying the claim unfairly. Reports indicated that less than 1% of IME doctors give an honest, fair medical report in favor of the injured worker.
I appreciate the information on the basics of independent medical examinations. I had no idea that you would have to get an independent medical examination for so many different instances. I would imagine that it is good to have an independent examiner so there isn’t really any bias when it comes to the exam results.