Behind the Diagnosis: How IMEs Protect Care, Costs, and Confidence

Medical Management: IMEs Help Ensure Appropriate Treatment

Adjusters, working on their own or in close collaboration with a nurse case manager, may notice unusual treatment patterns, such as sporadic or excessive treatment. These patterns may indicate inappropriate treatment that is not in the best interest of the injured employee, the employer, or the payer.

For most injuries, there’s a relatively standard treatment workflow and recovery timeline. This includes an initial medical visit, ordering any appropriate diagnostic studies, obtaining a diagnosis, outlining an initial treatment plan, and projecting a time frame for the injured employee to return to work (RTW), as outlined in the ODG guidelines.

In typical circumstances, the treatment plan would be followed, and the injured employee’s recovery would be monitored. When the time frame for RTW is reached, the injured employee would either return as outlined or be scheduled for an appointment for reevaluation. The end goal is to achieve a timely and safe recovery and return to work.

When the process deviates from this normal flow, it raises questions and concerns. Below are some examples of questionable treatment scenarios that may require an IME to obtain a second opinion:

• The injured employee. It is treated during a first visit, but there are no evaluation notes, and the injured employee is never provided with a clear diagnosis; or the injured employee was evaluated and told to return to start treatment, but there is no clear diagnosis or treatment plan. This could indicate a setup for over-treatment.
• The Treatment Plan. There may not be a treatment plan, or the treatment plan did not specify an “expected” timeframe for recovery and an anticipated RTW date. Anticipating when treatment will end is an important part of a treatment plan. If nothing else, a date should be set to reevaluate the injured employee.
• Sporadic treatment may raise concerns. For example, an injured employee may go in for treatment one day but not return for several weeks. At which point, the injured employee may be seen for a couple of days in a row. This would be unusual, particularly if the treatment plan calls for consistent treatment, e.g., once a week.

Special Concerns Around Musculoskeletal Injuries

When injured employees experience a musculoskeletal injury, a proven approach is to move that injury from passive care, such as receiving treatment, e.g., pain relief, physical or occupational therapy, to more active treatment, such as an exercise or stretching regimen. Active measures help restore, stabilize, and strengthen affected areas, and help the injured employee recover and resume the activities engaged in before the incident occurred.

However, if an exercise program is not observed in the treatment plan, it could lead to delayed recovery and more time away from work.

With soft-tissue injuries, claims staff should expect to see some form of recovery and improvement within a three- to four-week period. If not, adjusters should expect the treating physician to schedule a reevaluation to step back and say, “What’s going on? Maybe we need a different approach.” If there’s still no change or improvement, it could be time to order an IME to get another physician’s perspective on the diagnosis and treatment plan.

Injuries that include broken bones, on the other hand, may require a longer recovery time and include several weeks of non-weight-bearing activity.

Up next in the Case Resolution Series: From Setback to Comeback: IMEs That Drive Real RTW Results. Early intervention is critical—just three months away from work can cut return-to-work odds in half... and the longer it lasts, the harder it gets. Remember, proper action can change everything.

If you are ready to explore further, download the entire IME eBook here: Emperion eBook.

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