Brandy Davis: The New Adjuster’s Guide to IMEs, Part 2: Building Claims Judgment

Originally posted October 6, 2026 on WorkCompWire Leader Speak Read Part One here.

By Brandy Davis, RN, CLNC, Director of Quality Solutions, Compliance, and Provider Relations, Emperion

In Part 1 of this series, we covered the mechanics of an IME – what happens once one is ordered, what a physician looks at, and what separates a quality IME partner from one that’s just filling a request. That’s the “how.” This installment is about the “when” and “why” – the judgment calls that take experienced adjusters years to develop, and that newer adjusters can start building on much faster with the right framework.

Veteran adjusters often flag these patterns almost by instinct, without necessarily being able to explain why. For someone newer to the role or working through a caseload without a mentor down the hall, it helps to name the patterns explicitly. Here’s what to watch for.

The First Instinct to Build: Recognizing When a Claim Needs a Second Look
Most claims follow a predictable path – but when the pattern breaks, it’s worth paying attention. This is often the first instinct a new adjuster has to consciously train, since experienced adjusters tend to notice it without even thinking. Common warning signs include:

• Questionable diagnosis – a diagnosis that doesn’t align with the reported mechanism of injury
• Billing irregularities – unusually high evaluation codes or excessive procedures that suggest overtreatment
• New body parts – imaging or treatment for areas not part of the original claim
• Disproportionate pain reports – a pain level that seems inconsistent with the injury and time elapsed
• A focus on pain relief with no function-building – opioids prescribed without physical therapy or a home exercise plan
• Delayed return to work – an indemnity period that runs well beyond standard guidelines with no clear explanation

None of these signs alone prove a problem. But together, they’re exactly the kind of pattern an IME is designed to clarify.

Learning the Rhythm of Medical Management
Most injuries follow a fairly standard workflow: initial visit, diagnostics, diagnosis, a treatment plan, and a projected return-to-work timeline. Getting familiar with that normal rhythm is what makes it possible to spot when it breaks – sporadic visits, no clear diagnosis, or a treatment plan with no defined endpoint are all signals that a second opinion is warranted. For soft-tissue injuries specifically, claims staff should expect measurable improvement within three to four weeks; if that doesn’t happen, it’s a natural point to consider an IME.

Return to Work: Borrowing from Sports Medicine
The data here is stark: an employee out of work for three months has roughly a 50% chance of returning; after a year, that chance approaches zero. That’s why many claims organizations now apply a “sports medicine” mindset – treating injured employees the way a team doctor treats an athlete, with early intervention and a fast path back to modified or transitional duty.

50% chance of return to work for employees out three months

IMEs support this approach by helping determine maximum medical improvement (MMI) – the point at which no significant functional change is expected, often within the next 12 months.

A Vocabulary Every New Adjuster Needs: Impairment vs. Disability
One of the most misunderstood concepts in workers’ comp – and one that’s easy to get wrong early in your career – is the difference between impairment and disability:

• Impairment is a measurable loss of body structure or function (e.g., the loss of a limb)
• Disability is the resulting activity limitation or participation restriction (e.g., being unable to climb stairs, or unable to perform a specific job)

The same impairment can mean very different things depending on someone’s role. A lost finger might not disable a delivery driver from doing their job – but it could end a concert pianist’s career. This is why claims teams often rely on an IME for a second opinion on disability status, not just the medical diagnosis alone.

Workers’ comp disability is typically categorized four ways:

The Four Disability Categories

• Temporary Total Disability – fully prevents work for a limited time
• Temporary Partial Disability – limits some job duties temporarily
• Permanent Total Disability – prevents returning to any work permanently
• Permanent Partial Disability – permanently limits, but doesn’t eliminate, work capacity

Objective vs. Subjective: What IME Physicians Rely On
A defensible IME leans on observable, measurable findings wherever possible – not personal opinion. Findings generally fall into three buckets:

• Examinee-reported (pain, perceived range of motion) – inherently subjective
• Physician-assessed (palpation, measured range of motion) – a mix of both
• Clinically objective (blood tests, imaging, deep tendon reflexes) – the most reliable category

Physicians also watch for illness behavior – psychosocial factors like age, job satisfaction, or legal representation that can influence how someone experiences and reports pain, independent of the underlying medical condition.

Detecting Inconsistencies – Without Playing Detective
IMEs aren’t designed to catch fraud, and outright fraud is genuinely rare. But physicians do use validated tools to flag inconsistencies worth a closer look. Waddell’s Signs, for example, are five physical indicators that – when three or more are present – suggest a non-organic or psychosocial component to reported pain, rather than a purely physical one.

More often, what an IME uncovers isn’t deception – it’s a missed comorbid condition, a preexisting degeneration that predates the injury, or genuine symptom exaggeration the claimant isn’t even aware of. In each case, the benefit is the same: the claim moves forward on solid medical footing.

The Bottom Line for New Adjusters
None of this judgment shows up fully formed on day one – it builds claim by claim. But you don’t have to wait years to start recognizing the patterns, understanding the vocabulary, or knowing what a quality IME looks like. A well-executed IME does more than answer a single question – it gives claims professionals, at any experience level, the confidence to make informed decisions, keep treatment appropriate, and support injured employees on a realistic path back to work.

As the industry brings on more new adjusters to replace retiring veterans, closing this knowledge gap early is one of the simplest ways to protect claim outcomes – and to help newer adjusters build the same instincts their predecessors spent years developing.

For the veterans or claims leaders reading this: if this series would help someone you’re mentoring, share it with them. And if you’d like a quick-reference version to keep on hand or send along, both parts of this series are distilled into a one-page guide, available for download, along with other useful resources, here (PDF).

About Brandy Davis
Brandy Davis, RN, CLNC, is Director of Quality Solutions, Compliance, and Provider Relations for Emperion. A registered nurse with more than 20 years of healthcare experience, she brings extensive expertise in clinical care, quality management, peer review, compliance, and provider relations. Her clinical background includes Labor & Delivery, Post-Anesthesia Care, Pain Management, and perioperative services, followed by leadership roles coordinating physician peer review programs and quality initiatives for a large Level I Trauma Center. Since joining Emperion, she has advanced from Quality Assurance Specialist to leading the organization’s quality, compliance, and provider engagement strategies. As a subject matter expert in the disability and medical review industry, Brandy collaborates closely with medical directors, clients, providers, and operational teams to drive quality outcomes, support URAC accreditation standards, and serve as a trusted clinical resource across multiple lines of insurance.

Whether you are a new adjuster with new in career colleagues, or an experienced one mentoring a new team member consider passing this piece along. A five-minute read now can save a new adjuster from learning these lessons the hard way, on a live claim. And for quick future reference, we’ve distilled these fundamentals into a one-page guide you can download here (PDF).

About Brandy Davis
Brandy Davis, RN, CLNC, is Director of Quality Solutions, Compliance, and Provider Relations for Emperion. A registered nurse with more than 20 years of healthcare experience, she brings extensive expertise in clinical care, quality management, peer review, compliance, and provider relations. Her clinical background includes Labor & Delivery, Post-Anesthesia Care, Pain Management, and perioperative services, followed by leadership roles coordinating physician peer review programs and quality initiatives for a large Level I Trauma Center. Since joining Emperion, she has advanced from Quality Assurance Specialist to leading the organization’s quality, compliance, and provider engagement strategies. As a subject matter expert in the disability and medical review industry, Brandy collaborates closely with medical directors, clients, providers, and operational teams to drive quality outcomes, support URAC accreditation standards, and serve as a trusted clinical resource across multiple lines of insurance.

About Emperion
Emperion is a national provider of outsourced clinical review services including Independent Medical Examination (IME), Peer Review (PR), and Independent Review Organization (IRO) solutions. The company manages a national network of approximately 25,000 providers across a broad range of medical specialties. These capabilities promote patient recovery, return to employment, and successful claim outcomes across Workers’ Compensation, Automobile, Disability, and Health benefit systems.

Notes
¹ U.S. Bureau of Labor Statistics workforce data, via industry reporting, 2025–2026
2 U.S. Bureau of Labor Statistics projections, cited by the U.S. Chamber of Commerce, 2026.
3 https://www.iii.org/fact-statistic/facts-statistics-careers-and-employment

Disclosure:
Emperion has advertised with WorkCompWire.
This is NOT a paid placement.