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WHERE DID INDEPENDENT MEDICAL EXAMINATIONS GO WRONG?

By Damien J. Caldwell

 

 

So often today we hear about how the Independent Medical Examination (IME) or provider cost the carriers or employer the case.  The report was bad.  The physician did not address the appropriate issues or commented outside of his/her scope.  The physician did not include all the medicals in the report.  You name it and over nearly the past decade I have heard the complaint from my industry colleagues, vendor managers and pretty much anyone dealing with IME’s.  What has caused this deterioration of such a valued service over the years and who is to blame?

 

The reality is there is plenty of blame to go around for all parties.  Whether you request the service, provide the service or perform the exam as was pointed out back in 2007 through the NY Times articles that sent chills throughout the IME and Workers’ Compensation communities.  However, the fact remains that there is one main culprit in the demise of the IME.  Believe it or not, contrary to the opinion of some vendors, it is not the insurance companies or the physicians who are the main perpetrators in turning a once respected service into the near industry folly.  It is the IME Companies themselves.

 

To understand the perspective of this article we have to journey back 20 years when the industry was not dominated by national vendors and publicly traded corporations.  It was an industry which was run by small and mid-sized local and regional companies whose sole purpose for being was to provide IME’s to the claims industry regardless of line of insurance.  Because these companies derived one hundred percent of their revenues from IME Services their focus was to provide the best possible product and service to their clients.

 

When I entered this industry at a small regional IME company in Levittown, NY there was no greater emphasis placed than on ensuring that our clients received only the best.   Every file which we received was reviewed before a physician was even assigned to ensure that the adjuster was requesting the appropriate specialty and that the network provider would receive a detailed cover letter outlining key elements to be reviewed.  In later years, when I managed larger organizations, it was always an uphill battle to implement a similar structure.  Why?  Because to larger companies, the time to pre-review a file was not efficient.  Therefore, the process was frowned upon by the corporate executives as well as staff who had been accustom to just passing on scheduling to their coordinator who pulled a name off the list just to get the appointment out the door.  Right specialty, right location meant the right provider.  It was right to everyone except me and the client.  I would fight for my processes to be implemented and usually won.  However, immediately after I departed from an organization they would revert right back to their old ways much to the travail of their clients.

 

Back in the days of Yore, we used to receive reports and compare the reports and findings against the medicals to make sure that the provider listed everything we sent him.  Mind you, our medicals were organized and sorted chronologically for the providers.  Ask any medical professional today how he receives documents from a referring vendor.  Ninety-nine percent will tell you they receive a jumbled mess of papers, full of duplicate reports, bills and records.  If they are sorted it is not in any comprehensive order just a grouping of records.  In a conversation with a provider just a few weeks ago.  He advised me of a vendor that sent him a 1600 page file.  After he organized and cleaned up the file, there were really only 400 pages.  The rest were duplicates or non-medical related documents from the claim file (copies of envelopes, etc.)  If this is how the providers are receiving the files, then it begs the question how is the vendor reviewing to ensure everything is contained within the file or that the information reflected is accurate.

 

An example to this is the recent experience of a industry colleague who is house counsel for a local insurance company.  They had previously requested an examination for a liability case.  The report was provided and a year later the case docket came up and they began to prepare.  Upon examination of the report, they noticed that the medical records listed an office visit which was performed not by a physician, not by a nurse or any medical professional, but by their co-counsel on the case!  Needless to say the outrage at this blunder was tremendous as this was a high monetary valued case.  To this day I am not sure of the outcome and when I speak with my colleague I am afraid to ask for fear of inflicting some Post Traumatic Stress episode.  This is the level of quality and review that they were paying top dollar for and resulted in the inability to use the report and probably the indefensibility of that portion of their case.  When they questioned their vendor’s manager, the response was to the effect of it was a large file they may not have read it.  An “A” for honesty but Information my colleague could probably have gone without as it called into question the quality of every referral they sent to this vendor.

 

Flashback 20 years, a situation such as this at the company which ‘raised’ me in the industry would have resulted in minimally the reprimand (and possible physical lashing) if not termination of the reviewer who forward that report without question to the client.  Perhaps a little harsh, but in an industry where you are only as good as your last report, and your only product is endorsed by your reputation, it would be justified (especially if it results in the loss of a client).  Today’s IME market is dominated by corporate machines whose main goal is to improve their bottom line not their client’s outcomes.  Their main directives are to process as many examinations each month to meet the goals established by the corporate powers that be.

 

The results of this are evident everywhere.  Internally, they face little to no employee engagement.  The understanding of and concern for the services and clients is minimal.  The focus of management is to increase volume and productivity but not necessarily without the compromise to quality in product or services.  The minutes saved in not reviewing a file are spent in pushing through reports to be invoiced to meet the end of the month goals.  The providers they select are based on cost versus quality and appropriateness – leading to the use of these IME mills and providers who derive ninety percent of their revenues from the provision of medical examinations.  In a nutshell, the pride that the smaller local and regional vendors once had has been all but extinguished.  Carriers who sought large national programs with the illusion that they would receive the same quality in service from state to state are coming to realization that this is just not the case.

 

National providers whose core competency is not the provision of IME’s are often causing more work and in many instances problems for their clients.  The level of frustration from Adjusters and Risk Managers is at an all-time high due to complications from their vendors and they have begun to shift focus back to the local and regional vendors that remain.

 

It is this realization after 20 years in medical cost containment and claims that the industry for which I have a great passion for has been in a downward spiral, which led me to the decision to open my own company.  With the hopes of revitalizing the reputation and quality of the industry I have taken such pride in for the greater part of my professional career.  Service providers need to put themselves on notice and realize that their purpose for being is to alleviate their clients burdens not add to them.  They need to take pride once again in the product and services we provide.  They cannot be afraid to ask for a physician’s credentials and testimony history if they are going to be serving as an expert witness.  It is part of their inherent responsibility to do so as part of the initial credentialing.  As vendors governed by regulation and ethics we cannot honor requests to modify reports or suggest alternative treatment methods.  We need to maintain the integrity in our products, our providers and ourselves. 

 

Our role is to provide our clients with reports and ensure that the providers findings are objective, their reports substantiate their treatments and they have been provided with all the tools and information they require to provide an objective Independent Medical Examination.  The reality is the IME Company is the conduit for which all this takes place and the success and/or demise of the industry, reputation of the product and our firms is completely dependent on us, our company directives, philosophies and mission.  We need to make it a good one.

 

To conclude this with a quote by Vince Lombardi “The quality of a person’s life is in direct proportion to their commitment to excellence, regardless of their chosen field of endeavor.”  This is my philosophy and that of my company.

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