Best Practice: An Objective View of IMEs and Physician Review Services
Utilizing targeted physician review services and independent medical exams
concurrent with treatment rather than late in the life of a claim can improve
financial results and support maximum medical improvement.
Applying the right intervention at the right time is a key to maximizing
medical management results. Typically, a claims or risk management professional
requests an independent medical exam (IMEs) or physician review service late in
the life of a claim. Strategically shifting their use earlier when treatment is
rendered rather than after time has elapsed can result in lower costs for the
payor and employer.
The retrospective approach
For example, consider a low back injury claim. A year after the injury, the
worker shows little improvement and has not returned to work. At this point,
the claim already has developed significant lost-time costs for the employer or
payor. Litigation is likely. A claims professional requests an IME to support a
strategy to settle the claim and mitigate losses. An IME may support this goal
and help to close the case.
Paradigm shift can improve financial outcomes
Instead of waiting until after a case becomes complex, proactively integrating
physician review services or IME concurrent with medical management tasks can
help direct and channel care. Red flags could suggest to case managers and
claims professionals when intervention would be most beneficial to support a
claim settlement strategy. This earlier intervention can result in measurable
value through lower costs, improved outcomes and reduced incidence of
litigation.
Ideally, the claims professional works with the medical management company from
the day the claim is initiated to assess and develop a plan to achieve an
optimal outcome. When treatments deviate from the expected schedule – for
example, if the worker is still undergoing aggressive physical therapy at 60
days, despite guidelines that call for work hardening – an objective evaluation
may help get treatment back on schedule. This approach can decrease lost time
and medical costs.
Physician advisors add flexibility
A strategic approach to objective evaluations is not limited to IMEs. Employers
and payors may be able to achieve results by referring cases to physician
advisors who examine cases but do not see the injured employees. Peer review
may also prove to be a valuable option when working within limited timeframes,
particularly considering the typical 30-percent rescheduling/no-show rate for
IMEs. In addition, employers and payors in jurisdictions that prohibit IMEs may
be able to achieve results by referring cases to physician advisors.
An integrated program works best
The best practice is to integrate an IME or physician review service within a
comprehensive case management model that establishes which types of situations
and claims merit an independent assessment of the claimant’s condition.
Ideally, these flags are integrated into the bill review system that
automatically triggers notification to a case manager or claims professional
handler additional follow-up or review is necessary. Delayed return to work,
excessive testing, movement to one or more health care providers after 60 days
of treatment and multiple conditions occurring after the original diagnosis are
among the situations that might indicate a case that could benefit from an IME.
Online tools and referral criteria can facilitate the process. Targeting the
right cases improves results.
Communication leads to more satisfactory conclusions
Some claims examiners and employers might be concerned that the disabled worker
may feel threatened by a request for an independent evaluation during
treatment. It is important to be proactive in conveying the benefit that an IME
can bring by supporting the claimant’s safe and timely return to productivity.
Effective communication promotes employee satisfaction and proves a strong
correlation with timely return to work. An IME should not be positioned as a
step that will negatively impact the injured employee but as a step forward in
the claim settlement process.
By providing an unbiased view, independent medical examinations bring clarity
to medical and disability case management issues. Embedding an IME and
physician review services into the case management process makes it possible to
proactively identify potentially more problematic cases and to take action that
can decrease lost-time costs without compromising quality of care.