October 7, 2025 - Posted on WorkCompWire Leaders Speak (Read Part Two)
By Karol White, Senior Director of Operations at Emperion
In last week’s post, we described what Peer Reviews are, their purpose, the process, and their frequency in workers’ comp claims management. This week, we will do the same for Independent Medical Exams (IMEs), which are estimated to be used in 25-50% of the nearly 1 million lost time cases reported in 2023 for private industry by the Bureau of Labor Statistics (BLS).
Understanding IMEs
Unlike Peer Reviews, which don’t entail an examination, an IME is an exam performed by a physician who is an expert in a relevant field or specialty but is not involved in treating or monitoring the claimant’s health. The physician’s relationship with the examinee is confined to the ordered exam. IME physicians are objective evaluators, rather than treating physicians, for the examinee and, therefore, do not have a stake in the outcome of the claim. They are typically requested by the claims professional to help bring clarity to the case and support claim resolution. Here are some areas where an IME can provide useful information:
- Diagnosis: When a claims professional wants to ensure that the initial diagnosis was complete and accurate. Diagnosis is often one of the most important factors regarding a case.
- Causation: To determine if the condition, pain, or other symptoms experienced were in fact caused by the work-related injury—or another underlying issue or previous incident.
- Treatment: To determine if a suggested treatment plan falls within best practices, such as those outlined in the Official Disability Guidelines (ODG). For instance, they may want to get a second opinion on whether a certain procedure or surgery should be performed.
- Apportionment: Depending on the jurisdiction, an employer may be allowed to assign some portion of the disability to a pre-existing injury or condition, which may reduce the benefits for the workers’ comp injury. An IME can help in assigning appropriate apportionment.
- Impairment: Depending on the jurisdiction and the relevant nomenclature, the claims professional may want to determine if the injured employee has reached maximum medical improvement (MMI), if a permanent or partial impairment exists and, if so, determine the impairment rating.
- Return to Work (RTW): A claims professional may want an estimate on when the injured employee will recover and be prepared to return to work or determine if there might be temporary or permanent work restrictions.
- Prognosis: The claims professional may require a simple statement that projects medical treatment needs into the future. It can be as simple as the prognosis is “good” or “poor.” This helps to determine whether or not there will be future medical considerations.
In these situations, an IME can serve as a helpful tool to help claims staff make decisions, while also providing significant benefits to both the employer and injured employee.
The IME Process
Once the claims professional decides an IME could be beneficial, it is critical to work with an IME partner dedicated to recruiting, credentialing, and managing a network of qualified IME providers. These partners should be vetted to ensure that their provider credentialing and operational processes are accredited by the Utilization Review Accreditation Commission (URAC). URAC accreditation is a seal of approval that the organization has the processes and policies in place to evaluate the background and expertise of the IME physicians assigned to your cases. Accredited credentialing and operational practices will help you feel confident that the exams you request will be completed with the utmost quality while withstanding legal scrutiny.
Once you have determined who you will be working with, the steps below lay a solid foundation, facilitating a smoother and more effective examination process:
Claims Professional Steps:
- Provide all the necessary information to the IME partner ensuring that the claim is handled correctly from the outset.
- Submit complete medical records, ensuring that all relevant diagnostic tests are included.
- Clearly communicate the scope and objectives of the IME.
IME Partner Steps:
- Select the most appropriate, specialty and jurisdictionally matched provider for the exam.
- Schedule the exam at a mutually agreeable time for the individual and the examiner.
- Provide the examiner with the necessary scope and questions to be addressed.
- Communicate appointment times, including reminders, with all parties involved.
- Perform quality checks on the report prior to delivery.
- Deliver the final report to the claims professional.
Examining Provider Steps:
- Obtain a thorough medical history from the examinee.
- Review all medical records and associated diagnostic studies.
- Perform the exam to assess the examinee’s health, injury, or disability.
- Summarize and send the examination findings to the IME partner, in the form of a report, addressing all questions and objectives provided.
When IMEs are Beneficial
As shared above, there are several instances where IMEs can be beneficial. They are particularly useful in complex situations helping to bring clarity to one or more factors on a claim. The following is a list of specific scenarios where IMEs are likely the preferred clinical tool for your claims:
- Physical Exam is Required: IMEs involve an in-person physical examination, which can be crucial for assessing the current condition, causation, and functional limitations of the injured employee.
- Comprehensive Assessment is Needed: IMEs provide a thorough evaluation of the individual’s current condition, which can be essential for determining functional capacity and causation.
- Complex Lost Time Cases: For complex cases, where there are comorbid conditions or the individual has been or is expected to be away from work for an extended timeline, an IME can provide the necessary in-person evaluation.
- Medical Records Are Not Sufficient: If the case’s medical documentation does not clearly show the course of treatment, diagnoses, and interventions, an IME would be the best choice.
- Litigation Support: IMEs are often used in cases where litigation is anticipated, as they provide a detailed and comprehensive assessment that can be used in legal proceedings.
- Functional Capacity Determination: IMEs are ideal for assessing the functional capacity of the injured employee, which may not have been previously evaluated and is crucial for determining their ability to return to work or perform specific job duties.
In Conclusion
Claims management is rarely black and white. However, regardless of the clinical resource you choose, a few key factors are important to keep in mind:
- Timeliness: When clinical review is necessary, all requests should be made as promptly as possible to clarify issues early on. Once a case has started down a certain path, it’s more difficult to make a significant change in direction. If treatment appears to be deviating from normal guidelines, seek objective input before the plan proceeds too far to be able to make changes.
- Clear Objective: To obtain a useful result, it’s imperative to provide the reviewer with clear objectives and any specific questions that should be addressed in the final report. This allows the physician to understand what they’re being asked to evaluate—such as whether further care is needed, the level of disability (if any), or other concerns.
- Comprehensive Background: The reviewer or examiner should receive all relevant background information, including a complete medical record, diagnostic test results, job descriptions, and claimant statements—all well in advance of the review or examination.
About Karol White
Karol White brings more than 30 years of expertise in Independent Medical Examinations (IMEs) and Peer Review, with a proven record of leadership, customer service, and operational excellence.
Currently serving as Senior Director of Operations at Emperion, Karol leverages three decades of industry knowledge to deliver streamlined solutions and trusted support to customers across the workers’ compensation, disability, auto, and liability markets. In this role, she partners closely with clients, providers, and internal teams to ensure efficient operations, supporting successful claim outcomes.
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.