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Vet independent medical reviews for quality to help control comp losses: RIMS

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Malingering, exaggerating injuries and comorbidities are some of the issues that can complicate an already complex workers compensation claim, which is why experts say hinging a claim on a quality independent medical review can help mitigate losses, according to a white paper released Wednesday by the Risk & Insurance Management Society Inc.

Independent medical examinations are not without risk themselves, which is why firms should ensure that reviews pass a bar for quality, according to the paper, drafted by Michael Valasek, vice president of IME services for Wayne, Pennsylvania-based Genex Services L.L.C.

“With complex cases, claimants may seek legal representation,” states the paper. “In these situations, opposing sides may obtain IMEs to substantiate their respective opinions. As a result, a certain amount of contention and suspicion has come to surround the IME process, with some (workers comp) professionals feeling the exams further complicate case closure. Rather than bringing about clarification, some say decisions get bogged down and stalled, and injured workers get caught in the middle — not receiving the care they need in a timely manner.”

The concerns have helped create a greater demand for quality independent medical reviews to gain impartial insight into a worker’s condition to establish appropriate causation, treatment, disability and return-to work, according to the paper.

Highlighting what distinguishes an independent medical reviewer, the paper outlines one doctor’s experience with the process:

“For me, preparing for an IME starts three or four days before the actual exam,” Dr. Amir Reza Moinfar of Elite Orthopaedic & Musculoskeletal Center in Glen Burnie, Maryland, told Genex. “I start by reviewing medical records. In some cases, these files can be on the order of up to several thousand pages. It’s a good opportunity to familiarize myself with the particular claim and to potentially catch items that may be missing from the file. For example, if I’m going to assess whether a claimant can return to full duty, I need the job description. If a claimant has had surgery, I need to most certainly have access to the operative note. There’s still time to request any missing information in advance of the exam. This helps to make the process, in my opinion, more seamless, thorough and efficient.”

“When an IME physician gives an opinion, it needs to be based on medical evidence and based within a reasonable degree of medical certainty. There are legal ramifications that help hold an IME to a high standard,” Dr. Moinfar continued.