Fraud and Malingering: A Look at How IMEs Can Potentially Help Avoid These Scenarios
It’s not the intention of an IME to detect fraud or malingering, but in some cases it can help identify “red flags” that should be brought to the attention of claims adjusters. Fraud and malingering are legal terms and must be determined within the legal system—not by medical professionals. IME physicians provide only the medical perspective, which along with other considerations go into making these determinations.
Outright fraud generally involves intent to deceive and is rare. However, there are situations where examinees perceive their injury and pain differently than what is presented in medical evidence. Oftentimes, injured employees experience pain. They aren’t intentionally trying to game the system, but the pain may stem from another issue.
Those who exhibit symptom exaggeration are often unaware that they’re doing it. When an IME is utilized early and appropriately, these issues can be identified upfront, so adjusters can get claims on the right track from the start.
As a result, IMEs can lead to other benefits for injured workers, insurers, and the workers’ comp system in general. One is that it can identify red flags that could indicate a rare instance of fraud and abuse, but the more frequent benefit is that injured employees get the care they need for other medical conditions that could be covered and addressed outside the workers’ comp system.
Here are scenarios where unanticipated IME benefits occur:
Causation
We conferred with Ghazala Kazi, MD, MPH, regarding the cause of an injury.
“I’m an occupational medicine physician, so performing IMEs is my specialty,” she said. “I’m trained to determine work-relatedness. I don’t always conclude that a condition is not related to work. In fact, most of the time I conclude that it is work-related. With those cases, the insurer can proceed in providing the claimant with treatment. I’m helping the insurance company make a decision, and the claimant, who may have been struggling for months or even years to get the care they need. "
“Sometimes, if someone is injured, the mechanism of injury is obvious,” noted Kazi. “However, there are complex cases where I have to review studies to determine if there is a causal relationship between the condition and the work environment. An IME physician who has the knowledge and training in epidemiology understands the methods to draw this conclusion and is trained to read such studies. Only a physician with the right expertise can perform this type of analysis.”
The method that Dr. Kazi is referring to is the Hill’s Criteria for Causation – a set of nine criteria that provide epidemiological evidence of the relationship between a presumed cause (e.g., a work-related accident) and the observed effect (the worker’s injury).
In some cases, an IME will rule out the mechanism of injury as the cause of the examinee’s condition. For example, the IME physician may be asked to consider whether a “slip and fall” could have caused an examinee’s severe back injury. In such situations, IME physicians don’t determine if the claim is accepted or denied. They only provide a medical opinion it’s unlikely that this particular mechanism of injury caused that level of severity. The payer can then use the information to make a claim determination.
Consistency vs. Inconsistency
IME physicians try to determine whether medical evidence lines up to support the condition(s) listed in the claim. In some cases, they may perform a series of tests that uncover inconsistencies. Here, the examinee may be experiencing pain, but it may be due to another medical condition. IME physicians will alert claims staff to any contradictory information.
False Positives
Some IME assessments are designed to detect false positives. For example, a certain movement or palpation may not be physiologically capable of causing pain, yet the examinee reports severe pain during the assessment. This indicates the examinee’s pain response is out of line with clinical evidence. IME physicians can’t say whether the examinee is experiencing pain, but they know, physiologically, whether a given movement or touch would elicit that type or level of pain. Through this means, the IME physician may come to realize that symptom exaggeration is at play.
Comorbid Conditions
IME physicians may discover that it’s actually a comorbid condition that’s causing the pain. In this situation, the examinee’s pain is not due to the workplace injury, or the injury might have exacerbated preexisting damage from a comorbid condition. The IME physician has helped to uncover a medical issue previously overlooked. In this way, IMEs can help injured employees get the treatment they need, a significant benefit to their well-being.
Degeneration
IME physicians may also identify degenerative conditions. Muscles and other body parts generally tend to deteriorate with age, and degeneration may have begun prior to the injury. The injury could then trigger a cascade of medical issues, which in reality started to develop long before the injury.
For example, a woman occasionally experienced back pain prior to a workplace accident; however, the incident aggravated her pain. The IME physician would identify what damage resulted from the preexisting degeneration and what was specifically related to the workplace injury. The IME physician is trained to consider complex interactions, including the mechanism of injury, comorbidities, and deterioration. The physician provides this information to the claims adjuster, who then determines whether to accept the claim and what benefits are due to the injured worker.
On the horizon, From Insight to Action: The Smart Path Forward in IMEs. Mastering the intricacies of IMEs is no longer optional; it’s essential for claims professionals aiming to close complex cases efficiently and fairly. But the real question is: is your team truly prepared to make every IME count?
If you are ready to explore further, download the entire IME eBook here: Emperion eBook.
If now is the time to request an exam, visit our online referral form.