The independent medical exam is a valuable tool to move claims forward. But even the slightest error in the review process can make a big difference. In today’s Inside Workers’ Comp, Donna Bradshaw, vice president of IME services at Genex, explains why a strong quality assurance (QA) program is vital to any IME service.
Tom Kerr (TK): Donna, welcome back to our program.
Donna Bradshaw (DB): Thanks for having me, Tom.
TK: So, let’s jump in. Why is the QA process so important to IME?
DB: Well, that’s a really good question. The QA process really helps meet your client’s needs and expectations. Each client may handle a different line of business — such as workers’ comp, auto, disability — and within each of those lines, there may be regulatory or policy requirements which must be followed and adhered to.
So, it’s really important that you have a robust QA process which builds trust with clients, and it shows them that not only do we understand the different lines of business, we also adhere to regulatory or policy requirements.
I think one of the things that we do for each client which is really very important is we develop a client‑specific protocol, and we do that in conjunction with our QA team, our operations team, and the client. And that allows us to ensure that we are meeting the client’s expectations, know what the expectations are, adhere to them, and provide a high level of quality.
TK: Let’s dive deeper into the details. What’s involved in developing a good QA process?
DB: Well, one of the things I think is really important is there’s a clear understanding that the QA process actually begins with the receipt of the client’s referral. So, when a referral is received, it needs to be reviewed to ensure there is no deviation from any type of regulatory requirement, such as asking questions or using verbiage that’s not permitted by the regulations. When looking at the questions that have been submitted by the referral source, you want to make sure they’re very clear and very concise and they’re not open‑ended.
I think another item to look at is ensuring the requester has included any necessary forms which may be needed in conjunction with the IME. There are some states that require physical capability forms. There are some states that require an affidavit of recovery. So, I think those forms need to be included.
I also believe that it’s really important to have a medical director involved in reviewing random reports to ensure a high level of quality. Our quality manager is a registered nurse, and this has proven to be most beneficial, not only to our in‑house team, but for our clients as well because she can be used as a sounding board for those clinical questions, which revolve around quality. Are we picking the right specialty? Are we asking the right questions? Those types of things.
TK: What type of things do QA professionals look for when assessing an IME?
DB: You know, when you’re assessing an IME report, there are several items that you need to focus in on, and we like to refer to them as the “Seven Cs.” So, it’s important that everything is correct, consistent, complete, clear, corroborated, confined and conciliatory.
It’s really imperative that the claim information, the date, any jurisdictional language is correct, that the report is free of any typos. The report absolutely must be consistent. There can be no contradictory opinions.
And you have to be careful of those he-vs.-she or the left‑vs.‑right. You want to make sure if you have a female claimant, that she’s referred to as “she” throughout the report. The professionals ensure that the report is complete, such as all of the questions have been answered, all of the testing has been reviewed, and all of the report sections are included. So, in the body of a report, you want to make sure there’s a listing of medical records, a physical exam, a summary of the incident, a recap, and then address all of the questions.
You want to make sure that when reviewing the answers to the questions, the medical opinions are understandable, have easy readability, and include good grammar and punctuation. No run‑on sentences, and again, no typographical errors.
The QA folks will check to ensure the answers are corroborated by objective medical evidence and they’re free from subjective opinions. I think it’s really important to make sure the IME physician remains within the scope of the claim and limits replies to his or her specialty. You want to make sure the physician doesn't travel down a path outside his or her scope. So, if the exam focuses on a fractured leg, you want to make sure you’re staying with an orthopedic surgeon.
The QA professional also is going to confirm that each report is free of any potential inflammatory or insulting comments towards any party. That’s just not something that belongs in the body of an IME report.
TK: So, what could go wrong if a good QA process isn’t followed or completed?
DB: There’s a lot that can go wrong. Say, for example, the date of loss is incorrect in the body of the report, or the claimant is a female and referred to as a “he.” That’s going to call into question the validity of the entire IME report. If there are jurisdictions which have very specific regulatory requirements which, if not adhered to, will invalidate the entire process as well as the report.
In the event the IME provider includes a somewhat inflammatory comment in his or her report, it could bring into question the provider’s objectivity. These are reasons why you really should stick to and follow those “Seven Cs” to ensure that the IME report is well‑written, focuses on the claimant and the claim, and is succinct and objective.
Otherwise, what’s going to happen is you are going to run the risk of having that report invalidated and unable to be used to support the claim, whether it’s to determine whether further treatment is necessary or no longer necessary. You don’t want to invalidate that report. You want to make sure it’s just wrapped up nice and tight.
TK: What should workers’ comp professionals look for when assessing whether their IME network has a strong QA program?
DB: Well, I think workers’ comp professionals really do need to make sure that their network takes the time to meet and prepare those client‑specific protocols because that is really the first step in ensuring quality from intake to output.
This not only provides specific client requirements like I mentioned before, but it also is going to highlight any regulatory requirements, and that does ensure a high level of quality.
Additionally, I think you want to make sure your IME network has clinical staff, such as, registered nurses or licensed practical nurses, because they can assist in that quality process from, again, intake to output.
I don’t think that we should just be focusing on the quality of the IME report when it’s actually the entire process because if there’s a breakdown at any point in that process, then you’re running the risk of either the process, or the process as well as the report, being totally invalidated.
Another thing that is really important and that work comp professionals should look for is that a medical director is on board and that they do random reviews of IME reports. That medical director is ensuring those reports are well‑written, is utilizing evidence‑based medicine, and that there’s a level of compliance with those “Seven Cs” that we previously spoke about.
TK: Thanks, Donna. In our next Inside Workers’ Comp, we’ll look at how the latest ODG updates are affecting claims management. Until then, stay safe and thanks for listening.