Claim handlers are sometimes called upon to write cover letters to a medical expert in advance of an independent medical examination (IME). This can be a challenging process as some have either never written one or lack the proper training. It is crucial when drafting this latter to ensure the contents are factual and allow the expert to have their report admitted into evidence should a case go to a hearing. When done right, claim handlers can write exceptional IME letters.
Independent Medical Examinations (IMEs):
IMEs entail a referral to a physician for a comprehensive physical examination and responses to specific questions posed by claim adjusters.
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As with file reviewers, the right specialty should be selected for the exam, and the qualifications and standing of IME physicians must be established via a thorough credentialing process. Casual referrals to local physicians are often not the best approach; the use of vendors with established networks of IME physicians subject to careful quality control is recommended.
When is an IME appropriate?
- IMEs are not useful for:
- utilization review of services and drugs, except in a few exceptional circumstances.
- causation determinations, or treatment planning, both of which are relatively easy to accomplish based on a review of medical files and current familiarity with evidence-based medical practice guidelines.
- IMEs may be useful when a physical examination by the responding physician is important
- determinations of maximum medical improvement (MMI) status;
- definitive impairment ratings based on the impairment guide mandated in the jurisdiction of the claim.
- IMEs will hold greater weight in litigated claims, particularly when an appearance at a state board hearing is scheduled or anticipated.
Peer Reviews Should be the First Option
In general, peer reviews should be considered the first option for obtaining physician expertise, unless an IME is strongly indicated by the above criteria.
Scheduling the IME
If the use of an IME is determined appropriate, then the claim handler should prepare properly to make the outcome meaningful.
The IME should be scheduled with a reputable doctor who has training, experience, and practices in the area where the employee was injured. This can sometimes get complicated if a jurisdiction has restrictions on the distance an employee can be required to travel to attend the examination. Be prepared to reimburse in advance reasonable travel costs, lost wages for the time the employee will be gone, and mileage.
Important Items to Include
Several items should be included in a cover letter to a medical expert before the examination. It is also essential to provide that person with a complete set of medical records to review. Itemize what documents are being sent for review in the body of the cover letter.
- Introductory items:
- Date, time, and location of the examination;
- Note your position with the insurance carrier and the name of the insured;
- Identify the date of injury and impacted body parts. Specifically call out what body parts/conditions are admitted, and what parts are denied; and
- Describe the injury mechanism—reference how this description was obtained (recorded statement, eyewitness accounts, deposition testimony, etc.).
- Relevant medical history:
- Provide the medical history with a complete medical history of the employee. Be sure to include relevant information regarding their family background, education, and information on transferable job skills;
- Include a complete history of the work injury. This is important in the instance where the injury is cumulative, or causation is questionable;
- Ask the examining doctor to conduct a physical examination that pays particular attention to the boy parts included in the work injury; and
- Instruct the doctor to provide their findings and opinions with a reasonable degree of medical certainty.
- Note upcoming dates or litigation, and if time is of the essence to receive their subsequent report. Make sure the examining expert knows they can contact you if they have any questions.
The bottom line is to be factual. The cover letter sent to an expert is discoverable and can be admitted into evidence at a hearing on the merits.
Asking the Rights Questions
The IME is the one opportunity the defense has to have the employee seen and examined by a medical expert of their choosing. Make it count by asking the doctor to answer relevant questions. It is vital to emphasize the expert should include detailed explanations for their answers to gain credibility.
- Diagnosis and prognosis of the injury, and whether it is related to the employee’s work activities. Make sure the doctor is aware of the legal standard for causation, which is usually whether the work activity is a “substantial contributing factor;”
- A determination if the injury is temporary or permanent in nature. If temporary, be sure to ask for the date of resolution;
- Issues concerning permanent partial disability. Make sure they include the relevant statutory or regulatory citation;
- Specify the need for any restrictions on the employee’s activity;
Other questions concerning secondary gain may be necessary.
Claim handlers are sometimes asked to write an IME letter. This examination must be timely correctly. When writing the letter, be sure to keep in find it may be introduced into evidence. By being factual, including the necessary information, and asking the right questions, members of the claims team can write an exceptional IME letter.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is the founder & lead trainer of Amaxx Workers’ Comp Training Center, which offers the Certified Master of Workers’ Compensation national designation.
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