Helpful Tips When Requesting an IME
When to Request an IME or Peer Review
Below are a few tips for when to request an IME & Peer.
These are of course only examples, there may always be exceptions.
If you are not sure, give us a call, we’d be happy to help determine what may be most beneficial.
When to Request an IME
An IME is an objective exam used to evaluate the current physical and/or mental status of a claimant’s condition. This exam will help to determine causal relationship, appropriateness of treatment, need for further treatment or diagnostic testing, degree of disability, need for essential services, work capabilities/restrictions, etc., or any other questions you may have. Keep in mind that it is most beneficial to schedule your IMEs with provider(s) in the same discipline as the treating provider(s). Although some states laws may not require it, arbitrators and courts will agree that an opinion or claim denial may not stand as strong, if at all, if the independent examiner is not of the same discipline or specific expertise as the treating provider.
- If there is a large time lapse between when the accident occurred and when the claimant began to seek treatment.
- If mechanism of injury does not match claimant’s complaints.
- If there is, or is a suspicion of, a pre-existing medical condition.
- If the claimant is treating with several different providers, especially in the same clinic/location.
- Inconsistencies between providers’ notes.
- Any time there is excessive treatment (i.e. more than 30 visits of chiropractic, or greater than 4 weeks of PT for a simple soft tissue injury).
- If the claimant has been treating with the provider prior to loss (i.e. maintenance care with a chiropractor).
- If there are large gaps of time between treatments.
- If there is no reduction in frequency of treatment after an adequate course of conservative management.
- If no progress is made and there has been no change in treatment plan or referral to another specialist.
- If care continues after claimant has reached maximum therapeutic benefit.
- Keep in mind that Peer Reviews will be most useful on procedures or testing (i.e. NCV, EMG, MRI, surgery, supplies), not typically as useful on treatments (i.e. Peer of a claimant’s chiropractic treatments) – better to do an IME in this case.
When to Request a Peer Review
A Peer Review is a records review primarily done to determine clinical necessity of particular procedures or diagnostic tests, treatment protocols, medical supplies, or surgery. Peers can also be used to evaluate the role an underlying condition may have played on the injuries sustained in the loss. Although Peer reviews can be done to evaluate treatment, it is usually better to do an IME where the opinion is rendered after physically examining the claimant.
- Lack of supporting documentation to warrant the performance of a test or procedure.
- When advanced diagnostic testing (MRI/NCV/EMG) is performed earlier than 4-6 weeks of conservative treatment.
- If there is a large time lapse between when treatment began and when advanced diagnostic testing (MRI/NCV/EMG) was performed.
- When investigational diagnostic tests are performed, such as: Somatosensory evoked potential (SSEP), Dermatomal evoked potential (DEP), Sensory nerve conduction threshold (s/NCT), Current perception threshold (CPT), Surface EMG (SEMG), spinal ultrasound, thermography.
- When a mobile diagnostic testing company performs a test. Many doctors work with diagnostic testing companies to make extra money by ordering diagnostic tests whenever possible, and most often, unnecessarily. This over utilization is increasingly common and is extremely costly if not noticed. Most common fields of over utilization of these studies: Chiropractic, Physical Medicine & Rehab., Neurology.
How to spot a mobile diagnostic testing company
- When two bills are received: one for technical component (TC), another for professional component (PC).
- The professional component (PC) is being billed by either an out of state provider or an in-state provider far away from where service was rendered.
- Fees billed much higher than what is usual and customary.
- When a bill is received for numerous medical supplies such as thermophore, TENS units, traction units, support cushions, etc.