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• The Independent Medical Exam IME Who When and Why

The Independent Medical Exam IME Who When and Why

written on April 20, 2009 by COSEWorkersCompensation contributor

The greatest cost to the small employer who is not self-insured is incurred when a worker goes out of work on a work-related claim.  The amount of accumulated Temporary Total (TT) time an employee amasses is charged against the employer.  The premium is calculated based upon these costs and a reserve fund, which is often three or more times the actual amount of Temporary Total Impairment incurred.  This greatly will affect the premium and can throw an employer into a penalty category;  and not in a group-rating program. 

The second consideration is actual claim allowance and diagnosis.  Actuary premiums and set aside funds are calculated based upon the diagnosis as is a historical record of money spent correlated against ICD9 codes. 

The third expense for the employer is directly tied to the amount of treatment and medical costs incurred. 

An Independent Medical Examination is key in all three of these areas to define and limit reasonable time off of work, appropriate diagnoses and treatment incurred.  These are among the reasons to do an Independent Medical Examination.  When a new diagnosis or additional diagnosis is postulated by the treating doctor, osteopath or chiropractor for an injured worker, the request must be scrutinized.  It is common and almost routine for anybody with a musculoskeletal injury to request substantial aggravation.  As such, requests for substantial aggravation to injuries is not limited to musculoskeletal injuries, but has much more frequently in the recent past been extended to medical problems such as diabetes, cardiovascular disease as well as psychological conditions.  All of these must be carefully considered and moreover where appropriate challenged by expert medical testimony.

Any requests for time off for a work-related injury also must be analyzed.  The amount of time off must be minimized.  This is only accomplished by having the appropriate Independent Medical Examination performed in conjunction with a company that has a transitional light duty program and absenteeism control policy.  These are essential and key tools in minimizing Temporary Total Impairment and maximizing productivity.  Such a disability management policy from a company perspective ideally should not only encompass Workers' Compensation injuries, but in general all medical related disabilities and even preferably Family Medical Leave (FMLA) requests. 

Additionally a well-designed management policy protocol will allow the company to examine an individual more often and simply ordering an Independent Medical Examination would so allow.  This gives better control of absenteeism and the ability to return the worker earlier to the job or modified job as well as have a better handle on the amount of treatment costs being incurred on a regular basis. 

There are many treatments that are offered to the injured workers that are appropriate, used judiciously and attribute to the rehabilitation.  However, this is not always universally true.  The typical bill submitted by a chiropractor or other provider can be upwards of $250 and as much as $400.  By charging separately for massage therapy, manipulation, traction, ultrasound, electrical stimulation, hot packs, cold packs, neuromuscular education and other treatments during a one hour session, the total bill can easily reach these numbers.  If one multiples a three time a week treatment for six or eight weeks, the rehabilitation bill could easily exceed $10,000. 

Work conditioning and work hardening typically also is in the same range of charges from $5,000 to $10,000.  Requests for different procedures such as MRI scans and discograms can easily exceed $2,000 and often more.  If a MRI scan is done of several spinal parts for example, the cost could easily be $3,000 as would a discogram be more than that.

Procedure requests such as blocks are also not inexpensive.  A typical block may run anywhere from $2,000 to $4,000 depending on where it is done and at what institution.  Procedure costs such as radiofrequency ablation, IDET procedures and even Synvisc injections to joints approach several thousand dollars for each one.  Spinal cord stimulators and pain pumps when all is said and done including trial procedures, repositioning, implantation, re-implantation and re-positioning as well as in most cases removal can approach $50,000 or more.

All of these costs add up and will affect the company's ability to remain in group rating and also will affect their premium.  The affects of the premium can be tremendous and depending on the size of the company can have profound implications on their ability to continue business based upon the Workers' Compensation premium. 

For all of these reasons, an Independent Medical Examination is appropriate.  An Independent Medical Examination is a very effective tool in getting an individual back to work, minimizing Temporary Total Impairment and minimizing medical costs or at least ensuring that medical costs that are expended are valid, reliable, and appropriate and directed.  In cases where no settlement is possible or where the individual clearly is not coming back to work and the company and Third Party Administrators (TPA) often throw their hands up on how to handle the issue, then an Independent Medical Examination by the appropriate knowledgeable provider who will help in solving the dilemma and lead to resolution. 

Typically the experienced Independent Medical Examiner works with the attorney or the company to devise a strategy on how best to handle problematic cases, employees and issues.  You should find an examiner who is credentialed.  This means board certification with appropriate training leading to the certification.  The American Academy of Disability Evaluating Physicians (AADEP) is an organization that is made up of specialists who are specifically trained in doing Independent Medical Examinations.  This organization is composed of board certified orthopedic doctors, neurologists, neurosurgeons, occupational and environmental specialists as well as physiatrists and others who specialize in Independent Medical Examinations.  Members of this organization and in particular people who have Fellowship or Master Fellowship in this organization are highly trained in doing Independent Medical Examinations. Similarly the American College of Occupational and Environmental Medicin (ACOEM), has a certification program, and produces Board Certified doctors.

A good Independent Medical Examination examiner has good credibility.  Not only is the examiner credentialed and experienced, but this individual will have an established reputation with the BWC and insurance entities that they can be relied upon to offer opinions that are credible.  In other words, some injured workers do have legitimate medical problems, need appropriate treatment, need time off from the work environment and do need tests and procedures.  Where this is appropriate, the Independent Medical Examiner will so declare. 

Functional Capacity Evaluation when ordered and specifically directed by the Independent Medical Examiner who is experienced in this test, is another methodology of comparing objectively effort, true limitations versus symptom magnification and exaggeration.

One should not look for an examiner that always agrees with the TPA or the company saying that the individual can go back to work, should never be off and does not need treatment.  A good examiner will offer a credible opinion based upon scientific evidence.  By the same token, a good examiner will also look for signs of symptom magnification, deception and inconsistencies.  Where the objective physical findings or imaging studies do not match the complaints or pattern of pain, this must be pointed out.  Where there are inconsistencies in physical examination or symptom magnification (Waddell's signs-to be elaborated upon in later articles), this must also be spelled out.  The credibility of the patient and employee must also be judged on these particular aspects and these need to be pointed out to the hearing officer.

The experienced Independent Medical Examiner will provide a great deal of guidance to the company, the TPA and in some instances the attorney representing the company as how to approach the claim, the employee and the future.  The stakes are high and as such it is important to find an experienced, credentialed and credible Independent Medical Examiner.  One can always shop around for price, but like everything in this world what you want is value.  Value is only determined by the result achieved when compared against the cost.

 

This article is written by Dr. Kevin Trangle.  He is a Board Certified Internist, Occupational and Environmental Medical Specialist who is based in Cleveland with offices in Akron, Columbus and Youngstown.  He is on staff at University Hospitals/Case Western Reserve and has performed Independent Medical Examinations for over 15 years.  He has lectured widely in this area.  He has provided onsite consultation and developed programs in conjunction with COSE and other organizations throughout Ohio to help companies sort out their disability issues, lost time injuries and workers compensation and health productivity matters in general.  He is a Master Fellow in the American Academy of Disability Evaluating Physicians as well as a Fellow of the American College of Occupational and Environmental Medicine and in several other ancillary organizations. 

Kevin Trangle, MD, MBA

MDIMEX Associates, Inc

Office 216-504-0400

3609 Park East Dr. STE 202

North Building

Beachwood, OH 44122

www.mdimex.com