On the importance of a systematized process and collaborative approach between the adjuster and Independent Medical Examination vendor in order to facilitate selection of the most appropriate practitioner(s) for an IME
By Sean Cassidy, Vice President – Sales & Marketing, Benchmark Independent Medical Examinations
Oakville, ON (Nov. 13, 2014) – Independent Medical Examinations are a very important part of the Accident Benefits claims adjudication process. Based on 52 studies conducted across North America which focused on the rate of malingering, estimates of symptom over-reporting among claimants presenting to IMEs ranged from 16% to 55%, with studies at lower risk of bias finding higher estimates. Of particular interest is the finding that IME examiners reviewing the same case often demonstrated little agreement regarding the actual degree of impairment that should be assigned.(1)
At Benchmark Independent Medical Examinations (Benchmark IME) it has frequently been our experience that the composition of a multidisciplinary team and the scope of practice of the individual practitioners selected to be part of the team can make a large impact on the overall accuracy and defensibility of the final opinion. It is critical that strict standards and criteria be followed when selecting the appropriate practitioner(s) to perform an IME and when conducting an IME. Using a systematized and collaborative approach would be more cost effective but also much more accurate and defensible with respect to the final opinion. The ultimate goal of an IME is to provide an objective, defensible, and impartial opinion to a third party to assist them in the claims adjudication process.
We feel that the IME vendor needs to collaborate with the adjuster to select the most appropriate practitioner(s) or combination of practitioners in terms of expertise and scope of practice, in order to address the issues/benefits in dispute. To do this we believe a standardized, systemized referral process is a necessity so that the IME vendor and adjuster form an efficient team dedicated to selecting the best practitioners. Below we have listed four examples of the collaborative approach between our staff and our referral sources that have ensured that the most appropriate practitioner(s) were addressing the benefits/issues in dispute.
A catastrophic impairment determination request was initially received for a Physiatry examination only to provide impairment ratings as per Criterion 7 of the submitted OCF-19. However, based on a thorough review of the file documentation, we determined that the claimant had multiple pre-existing orthopaedic/mobility issues, which needed to be addressed in terms of whether there were any current orthopaedic restrictions and with respect to causation, since the claimant also sustained orthopaedic injuries during the accident in question.
While, in our opinion, the Physiatrist was the best choice in this determination to provide the overall impairment rating and to determine the claimant’s overall rehabilitation needs at that point (an additional issue to be addressed), we suggested an Orthopaedic Surgeon be added to the team to identify and delineate the impairments that were attributable to the claimant’s pre-existing condition versus those injuries and impairments that were attributable to injuries sustained in the subject accident. The addition of an orthopaedic examination permitted the physiatrist to provide a much more accurate and narrowed impairment rating based on injuries sustained in the accident. As such, the orthopaedic surgeon provided the necessary clarification with respect to causation and both examiners were able to collaborate to arrive at a more accurate impairment rating.
A request was received for a psychologist to address a disputed OCF-18 submitted by a psychologist for treatment and medication expenses; the issue of medication expenses was also in dispute. Furthermore, the claimant had a significant pre-existing psychiatric history and had been regularly seen by a psychiatrist prior to the subject accident.
Given the significant pre-existing psychiatric history and the claimant’s presentation during other examinations – which was only determined through a thorough review of file documentation –and the fact that medication was potentially being prescribed for a pre-existing condition, a recommendation was made to the referring party that the disputed OCF-18 would be more appropriately addressed by a psychiatrist, particularly since comment on medications was outside the scope of a psychologist.
Chronic pain is increasingly diagnosed, and we are finding that, due to the nature of a pain complaint, it is crucial to not only have a practitioner who can address the sequelae of accident-related injuries, but a practitioner who has the necessary expertise with respect to the diagnosis of chronic pain and the latest treatment modalities. Furthermore, as there is often a psychological component to this diagnosis it is also important to determine whether a psychological examination would also be required to address the identified issues.
In a recent referral the Orthopaedic Surgeon had recently examined the claimant to address the Income Replacement Benefit and the referring party requested that the same orthopaedic examiner address a disputed OCF-18 submitted by a chronic pain program proposing a medical assessment, botox injections, and other services, including counseling.
In consultation with the referring party we recommended that the OCF-18 be addressed by a general practitioner with expertise in pain medicine and the use of botox rather than being addressed by the orthopaedic surgeon; particularly as the general practitioner would have the benefit of reviewing the orthopaedic examiner’s findings to make his/her determination. We also recommended that a psychologist be added as the issue of whether mental health services were indicated would be more appropriately addressed by a mental health examiner.
Another common scenario is receiving referrals to use more practitioners than are actually required for a determination. An example is the case where a claimant sustained a peripheral nerve injury in the subject accident and had no pre-existing neurologically-related conditions. As per the documentation reviewed by the clinical staff (including the records of the claimant’s neurologists and a recent orthopaedic insurer’s examination report), there were no remaining neurological difficulties or complaints present at the time of the referral. The referring party had initially requested both neurology and physiatry opinions; however, given the claimant’s status at referral, we recommended that the referring party proceed with the physiatry examination first to address the claimant’s neuro-musculoskeletal status and if a neurology consultation was deemed necessary as per the opinion of the examining physiatrist, that a neurology examination would be scheduled as well.
These are just four of the many examples we could provide that demonstrate the Accident Benefits practitioner selection process needs to be standardized, systemized, and collaborative. To address this challenge at Benchmark IME we utilize an online referral system, which is connected to our intuitive and organized database, which makes it easy for referring parties to communicate with our intake/clinical staff and select the appropriate practitioners throughout the life of a file. Similarly, modifications and additions can be easily made by the referring party and the staff at Benchmark IME.
In summary, we feel that this provides a proactive process where the IME and the adjuster can truly work in an efficient and collaborative manner and ensure that the most appropriate practitioners are selected for each file with the outcome being the most accurate and defensible final opinion.
1. The studies were conducted at McMaster University, Hamilton, ON, Canada; University of Toronto, Toronto, ON, Canada; and Basel Academy of Swiss Insurance Medicine, Basel, Switzerland.
About the Author
Sean has been active in the insurance claims handling space in various capacities since 1997 and was one of the pioneers of Canada’s first online claims management system launched in 1999. Sean has expertise in claims, claims process improvement, vendor programs, claims IT systems, and document management. He enjoys working with insurance companies to tie all of these components together with their various systems and processes in order to arrive at the ideal combination customized to an insurer’s own unique needs. Sean joined Benchmark IME in December of 2013 and is putting his experience, coupled with Benchmark’s advanced technological capabilities, to work to improve the AB claim workflow for insurers in Canada.
Sean can be reached at [email protected].
Canadian-based, privately owned and operated by a Regulated Healthcare Practitioner, Benchmark is a national provider of Independent Medical Examinations.
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Source: Benchmark IME