Claims Management: IMEs Provide Expert Insight to Take the Next Step
In workers’ compensation, injured employees have an opinion about their condition, treatment, or ability to return to work. In some cases, this opinion may not be supported by existing medical evidence. Without clear, objective medical evidence, the opinion is usually called into question or at least needs to be confirmed. The opinion could be based solely on the injured employee’s perception, or it could be supported by a treating physician, chiropractor, and/or an attorney representing the case.
By law and ethical practice, the goal of employers, payers, and claims staff is to fairly cover the injured employee’s medical care and time away from work. However, they also want to guard against conditions for which they are not liable, inappropriate treatment, and potential abuse of the system.
When opinions are in question, adjusters can request an IME to obtain a third-party perspective. What follows next are a few scenarios that might alert an adjuster to issues for which an IME can help provide clarity. This list, by no means, represents all possible scenarios that may trigger the need for an IME, and in subsequent posts, we’ll cover additional medical and RTW issues that may warrant the need for an IME.
Scenarios that may require an IME to obtain a second opinion include:
- Questionable Diagnosis. There may be a diagnosis that seems inconsistent with the mechanism of injury or clinical findings.
- Billing Issues. Billing or coding on a claim may seem inappropriate. For example, a practice may use a high level of evaluation or management codes. These types of codes are typically used when an injured employee has experienced a severe or permanent disability. In a chiropractic setting, there may be billing around multiple spinal regions and extra spinal manipulations. These types of billing and coding issues may indicate signs of overtreatment, depending on the severity of injury. (It may just be overbilling, which is another issue worth addressing).
- Body Parts. When a claim is first reported, the affected body part or parts are documented. As time elapses, an adjuster may notice medical services for other or additional body parts. For example, an imaging study might be ordered for a different region of the body than those initially documented in the claim, or there may be repeat X-rays of an area without clinical justification.
- Questionable Pain. The injured employee may be reporting an ongoing level of pain, such as a 9 or 10, which may seem inconsistent with the injury. For example, perhaps an employee jammed his finger in a door. This would initially be very painful, but not likely to produce an unbearable level of pain that’s rated at a 9 or 10 several weeks after the accident. The incongruity may indicate the injured employee is exhibiting symptom exaggeration.
- Focus Only on Pain Relief. An adjuster might see an overemphasis on pain and pain relief with no effort to restore function and resume activity. For example, the injured employee may be prescribed opioid painkillers but not be scheduled for physical therapy or a home exercise regimen.
- Delayed RTW. An injured employee may have a longer than normal indemnity period—beyond ODG guidelines for that particular type of injury. Additionally, it may not be adequately explained by the treating physician or in clinical documentation.
Next time on, On Point: Behind the Diagnosis: How IMEs Protect Care, Costs, and Confidence). Spotting red flags early ensures smarter care and faster recovery—but what happens when the signs are missed?
If you are ready to explore further, download the entire IME eBook here: Emperion eBook.
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