Getting the Most Out of Medical Evaluations

It’s important to understand the medical evaluation process since it is commonly requested in all lines of insurance, according to Richard Stopek, COO of the Fla.-based Exam Coordinators Network.

He spoke on the topic at the Property & Liability Resource Bureau ’s national conference held in Indianapolis last month.

According to Stopek, who is a licensed chiropractor, there are three main characteristics of an independent medical evaluation (IME):

• It is independent. The doctor must arrive at his/her own diagnosis and treating guidelines, independent of the referring source. He or she is not involved in the care of the claimant.
• The medical review. Typically entails the review of the medical history of a claimant, the physical exam, and a comprehensive review of the medical records and diagnostic studies.
• The physical exam.

An IME differs in several ways from a regular physician visit:

1. Evaluation capacity only.
2. No malpractice because no doctor patient relationship.
3. Scope determined by what insurer/adjuster want to know, i.e., causation, pre-existing conditions, further care, supportive care, etc.
4. History taken by IME doctor is more comprehensive than history taken by treating doctor.
5. Physical exam is primarily for objective documentation of claimant’s status and impairment rating versus diagnosis and treatment.
6. Usually a one-time visit versus multiple visits to treating physician.

Stopek said that if an IME is not feasible, an independent medical records review (IMR) may be done instead. An IMR does not include a physical exam. Another alternative is a peer review, used where the extent of injury, causality and permanency is unclear or in dispute. The treating doctor may be contacted by the examining doctor. Yet another alternative is a radiology review, used when an opinion and IME is not required or feasible.

A benefit of an IMR is that it is useful for negotiations in liability claims.

Adjusters handling workers’ compensation claims will often obtain a functional capacity evaluation (FCE). An FCE is used to determine what an injured party can do to identify a level for successful return to gainful employment and to establish a baseline level of function, Stopek said. It is typically conducted by a physical therapist.

He emphasized that the IME provider specialty will likely depend on the stage of the claim and any specific issues. Appropriate specialty considerations include current treatment providers, past treatment providers, condition and diagnosis, future treatment recommendations, pre-existing issues, and any current issues.

IME reports tend to document who was present at the exam, and will contain formal and informal observations. So, a report could contain information on whether a claimant had difficulty walking in to the office or sitting in the waiting room. Anything that is observed or said will be reported as well as information on a claimant’s hobbies, involvement in sports and social functions. The report will also include a detailed past medical history.

The opinion section of the report may include comments on the following:

• Apportionment;
• Prognosis;
• Disability;
• Impairment;
• Maximum Medical Improvement (MMI);
• Permanent and stationary;
• Future medical;
• Causation;
• Diagnosis;
• Supportive care.

As far as the timeline of an IME, Stopek said that the exam date will generally occur two to three weeks after an appointment has been set. An adjuster can expect to receive a report within five business days of the exam.