Workers' Comp

Examining the Exam: It’s Time to Rethink the Independent Medical Exam

January 27, 2023

Randy McKinney

Senior Vice President, IME and Specialty Services

Traditionally used as a critical second opinion in auto, workers’ compensation and disability, the independent medical exam (IME) is a standard strategy often used as an option to address lingering and high-cost claims, disability durations and return to work. However, as an industry, we need to push for IMEs that go beyond simply looking at cost-cutting measures and demand IMEs that provide transparency, better communication, and a more strategic approach. We also need to take a closer look at IMEs and when they can be used most effectively during the claims process. The result will be better care for the individual and better claims resolution for payers.

Key Tips for Using IMEs

To reach this goal, we need to review how the use of IMEs has changed over the years. The following five trends can help build stronger and more effective claim programs.

Understand the models. There are two different business models for IME: clinic and panel/network delivery. Under the clinic model, individuals are sent to providers at medical clinics owned and/or operated by IME companies where evaluating insurance claims may be their primary role. In the panel/network model, individuals are seen by independent specialists, who are medical providers in active practice who examine the individual at their office site, often with training or expertise in a specific injury or illness.

Tip: Determine which model best fits your IME utilization strategy. No matter which model you choose, utilize local physicians who understand the market, follow industry-recognized treatment guidelines, and strive to meet community standards.

Match the provider with injury/illness. There is an adage in the health care industry: Use the right provider for the right injury at the right time. For example, a general practitioner is not equipped to offer the same quality of review for a traumatic brain injury (TBI) as a neurologist who specializes in TBI.

Tip: Encourage claims handlers to identify an IME provider who is a “specialty-to-specialty” match of the treating physician. This will save time and money and make the exam more credible to all involved parties, which in turn will lead to a swift and optimal resolution of the claim.

Start the process earlier. Historically, IMEs were conducted two or more years after a claim was initiated. That may be too late. Bringing in an expert managed care partner to help analyze your data and benchmark against industry best practices can help highlight claims that can go off track and result in inflated costs. That same data analysis can also identify claims that may benefit from an earlier IME resulting in quicker resolution. When an expert specialist can show a treating physician the value of an alternative approach, new therapies and modalities may be incorporated into the treatment plan, improving outcomes and, potentially, lowering costs.

Tip: Conduct the IME earlier on complex claims so the results may be used as a medical proxy for treating physicians.

Consider comorbidities. One of the most challenging and controversial aspects of claims resolution is determining whether an injury occurred because of the reported accident or is the result of a pre-existing condition. An IME can help clarify the causation.

Tip: Payers need to take every step possible to ensure their IME utilization is focused on what is best for the individual. The process should be transparent, and pre-existing conditions found to contribute or cause an injury must be supported by medical findings.

Develop an IME strategy . Lingering claims with no clear resolution date are costly. A strategy that incorporates an IME to better identify when to settle or how to resolve a claim can help payers set reserves and have better data for planning. Additionally, early IME intervention ensures that the injured employee receives the most appropriate treatment and can provide guidance on getting complex claims back on track.

Tip: Use your data and work closely with your managed care partner to identify claims at risk of becoming complex and use an IME to change the trajectory.

Making the Grade

A more focused and timely use of IMEs is a strategy worthy of consideration by payers seeking to develop initiative-taking programs that identify risk early and apply actionable steps to resolve the risk before it escalates. It often results in a better treatment protocol for the individual, faster and more favorable resolution of a claim and stronger protection against litigation.