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
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.