Thought Leadership

The Quality Divide: Is Your Vendor Driving IME Excellence?

Posted by Genex on November 27, 2017

By Michael Valasek, Vice President, IME Services

The demand for quality has given rise to an IME service industry aimed at connecting the best, most-qualified physicians to organizations requesting these exams and to the claimants who must undergo the evaluations.

Although the basic functions of the IME have remained the same, the nature of the industry has changed tremendously to meet demands for a greater level of service and clinical excellence. In fact, workers’ compensation (WC) insurers have moved from using many small mom-and-pop shops to establishing a preferred list of best-in-class IME companies that have an extensive geographic reach, a team of medical experts, clinical coordination, quality assurance processes, efficient workflow and an advanced technology platform.

As sophisticated IME companies – like Genex Services – have emerged, they strive to structure their enterprises to facilitate a quality IME each and every time – which provides significant benefits to the industry. Criteria for enabling a quality IME include the following:

Objectivity. When requesting an IME, objectivity is of utmost importance. If you work for an employer or insurer and request an IME directly from a physician, there’s a perception that you’re recruiting and paying this doctor to provide a specific medical opinion. Whereas, if you engage a third-party IME vendor, impartiality is built into the process. This vendor identifies an expert qualified to evaluate the case, and since the IME vendor has no “skin in the game,” they have no bias in the outcome. They simply recruit the most qualified expert to provide an independent, impartial opinion.

Quality Providers. A quality IME company will have relationships with a broad pool of medical experts. It evaluates physicians to make sure they are skilled at performing IMEs, don’t have sanctions filed against them and have active treating practices. The IME company is familiar with the physicians’ areas of specialty, board certifications and expertise on body parts, such as orthopedic surgeons who are specialized in hands versus knees.

Clinical Coordination. When an IME is ordered, the vendor has trained clinical coordinators who help to organize medical records, highlight critical pieces of the file, and identify items physicians should specifically review and consider in relation to the IME objective. For example, if the purpose is to assess causality, the coordinator will ensure all diagnostic test results are included and available for the physician to review.

Quality Assurance. The vendor ensures that the final IME report is carefully vetted through a clinically focused process to ensure a quality end result. Obviously, the medical opinion is solely that of the examining physician. However, the IME company will review the report to ensure a clear medical opinion is expressed and that the report addresses all the questions put forth by the claims staff.

Jurisdictional Expertise. The IME company must have in-depth knowledge of various jurisdiction requirements, such as when, why and how often IMEs can be requested. Each jurisdiction may use different evaluation guidelines, language and notifications. If state rules are not followed (for example, if the claimant is not given sufficient advanced notice), an IME may be disallowed.

Efficiencies. A sophisticated IME company has set up consistent, efficient processes across a national marketplace. It streamlines workflows around scheduling, intake, coordination, quality assurance and report delivery – all of which minimizes delays and improves communication throughout the process. The vendor has also fostered strong relationships with IME providers, so it can promptly schedule an exam and obtain a quick response.

Accreditation. As the bar for service continues to rise, sophisticated IME companies have obtained external accreditation. Through organizations such as URAC, an IME company can validate its use of best practices regarding data security, quality business processes, and HIPAA standards. For insurers looking to create a short list of vendors, URAC accreditation offers a stamp of approval that the IME company meets high quality standards. Currently, only a select few IME companies are URAC certified.

Digitation of the IME Process. A sophisticated IME company has made strategic investments in infrastructure. It has built systems and processes to work more efficiently with claims and provider communities. Digital portals have been established to securely and electronically transfer medical records between claims staff and IME physicians. These portals significantly streamline workflow, as the process of copying and shipping medical records is eliminated.

While quality vendors lead a march toward excellence, others lag behind. Using a “lagging” vendor can lead to claims that become prolonged, complicated and costly – with injured workers in danger of not receiving the care they need to recover and return to work.

It’s important to understand the factors that point to “leading” vendors with whom it’s smart to partner. These companies have made it their priority to develop and consistently adhere to IME best practices. They have built processes that deliver not only savings, but also superior service and credible IMEs that withstand scrutiny by state commissions, WC boards and court systems.

DOWNLOAD PDF

 Read Part 1