Many U.S. workers who file for disability insurance benefits have straightforward claims.
Others claims are not as clear-cut, and that’s where independent medical evaluations are beneficial.
Occasionally, claimants and their agents question the necessity of an IME and, therefore, it is important to educate those involved in the claim management process about the purpose and value of an IME.
Managing a disability claim can be complex, and there are times when a claims analyst needs more information to provide an initial claim determination or help decide whether a claimant continues to be eligible for benefits.
An IME is an excellent tool for this purpose, in that it can help employers, insurance companies and third-party administrators, among others, gain an objective medical assessment of a claimant’s condition. An IME also can provide the claims analyst with the information needed to fully understand the claimant’s medical condition, level of impairment and prognosis. Whether an IME is appropriate depends upon the unique facts of the claim.
Of course, IMEs come at a financial cost. Therefore, understanding which particular areas of the claim require clarification, and why, is essential.
For example, an IME would not be the best choice if:
o There is a preponderance of evidence that supports (or does not support) the disability claim.
o Any further information obtained will not affect the claim’s handling.
o Prior IMEs have been conducted and no significant change in condition has been determined.
How Do IMEs Work?
IMEs are performed by board-certified physicians who are not involved in the care of the claimant. Their role is to provide impartial information for case management.
Given that the role of a physician in the physician-patient relationship tends to be–and should be–that of the patient advocate, an opinion from an independent physician brings a level of objectivity to the process.
A treating physician’s role may affect physicians’ ability to make an unbiased diagnosis and, in some cases, to recognize factors such as behavioral problems, symptom magnification and secondary gain issues related to any potential ongoing legal or financial matters. Furthermore, physicians are not always trained to assess functional capacity, and may fail to accurately assess a claimant’s true physical abilities relative to the diagnosis.
An IME can be used at any point in the life of a disability insurance claim. It can be particularly beneficial at the initial claim determination, or when a claimant has been collecting benefits for a period of time during which the definition used to determine eligibility for additional benefits changes from “own occupation” to “any occupation” (as typically stipulated in the plan summary description).
It is important to ensure that the claimant’s condition is stable or at maximum medical improvement before conducting an IME, particularly at the change in definition. Conducting an IME too soon limits the ability to evaluate the claimant’s full functional capacity.
It is also important to work with a physician whose specialty qualifies him/her to assess the claimant’s specific condition.
The typical IME requires a single visit with a physician. However, there are rare instances where an additional exam may be needed depending on case specifics. An exam is similar to most routine medical appointments, including a comprehensive review of the claimant’s history, medical records and any applicable tests or diagnostic studies.
o Determine the diagnosis
An IME can help to confirm and/or identify the diagnosis and ensure that all diagnostic avenues were pursued in the evaluation, so that the claims analyst has a comprehensive understanding of the condition.
o Consider non-medical factors
Physicians conducting IMEs are trained to consider non-medical factors when assessing the claimant’s disabling condition. For example, a claimant may file a claim for a long-standing condition, although it may not be a condition that necessarily restricts or limits the claimant from performing the claimant’s occupation. Other factors–such as a potential layoff, an unresolved issue with a supervisor, or overall job dissatisfaction–may have contributed to the claimant’s decision to file the claim.
o Clarify the level of physical function or impairment
An IME can confirm and/or clarify the level of physical function or impairment to determine the claimant’s functional capacity (e.g., what the claimant can or cannot do). The evaluation helps clarify the prognosis and expected duration of the claimant’s condition, thereby aiding the analyst in determining appropriate next steps in the claim process.
o Establish appropriate treatment
An IME can establish appropriate treatment and help assess whether the claimant’s treatment program is effective in aiding his/her recovery. IMEs also provide the claims analyst with greater insight into the patient’s care and the level to which the claimant is receiving appropriate medical treatments. Sharing the results of the IME with the treating physician and establishing a protocol of care is key to accelerating the recovery process and enabling the claimant to return to a productive work life.
o Uncover potential treatment alternatives
The IME physician may provide recommendations for other avenues of treatment such as alternative medications or a modified physical therapy program. Again, this is important information that should be shared with the treating physician to optimize the claimant’s medical care.
Additional Claims Analysis Tool
If an IME does not provide sufficient data to answer all of the questions regarding the claim, the process can be taken a step further and a formal functional capacity evaluation can be requested.
FCEs are used by claims analysts to gain a better understanding of the full scope of the claimant’s functional ability, such as lifting capacity, hand-grip strength and tolerance for standing or sitting. Specifically, the FCE will demonstrate the claimant’s minimum physical ability based on his or her voluntary performance.
An FCE does not always reflect a claimant’s maximum ability. FCEs reflect what the claimant can do–or is willing to do–making it critical for the FCE examiner to perform validity testing to ensure that reliable data has been gathered during the examination. It is important to note that an FCE request must be submitted to, and approved by, the claimant’s treating physician before scheduling the exam. Additionally, FCEs do not need to accompany an IME and can be used as a stand-alone resource.
Key Points To Remember
If it is determined that an IME is necessary to evaluate the initial claim or status of an ongoing claim, it is important for someone on the claim management team to:
o Conduct an in-depth telephone interview with the claimant to ensure the medical portion of the file is complete and reflects any change in the claimant’s medical condition. This is an excellent opportunity to gain an understanding of the claimant’s daily activities.
o Set expectations with the claimant. Explain the rationale for the IME, review logistics and possible outcomes.
o Ask the right questions of the IME provider. For example, claims analysts should not ask the physician to assess whether or not the claimant is disabled, but rather identify restrictions and limitations, as well as the prognosis and anticipated duration, etc.
o Send a copy of all the medical records to the physician conducting the IME as well as any surveillance documentation that could assist the physician in the evaluation of the claimant.
o Review the IME report in a timely manner and confirm that all questions were fully addressed. If the IME physician does not address all questions, request further clarification. Use in-house medical staff (if available) to review the IME and provide any suggestions/recommendations for follow-up questions to be directed to the claimant’s physician.
o Send a copy of the IME to the claimant’s physician. It is a good opportunity for the claimant’s physician to provide comments or additional information regarding the claimant’s condition.
o Identify next steps to move the claim forward.