Independent medical examination
An independent medical examination (IME) occurs when a doctor/physical therapist/chiropractor/psychologist/neuropsychologist who has not previously been involved in a person’s care examines an individual. There is no doctor/therapist-patient relationship.
IMEs may be conducted to determine the cause, extent and medical treatment of a work-related or other injury where liability is at issue; whether an individual has reached maximum benefit from treatment; and whether any permanent impairment remains after treatment. An IME may be conducted at the behest of an employer or an insurance carrier to obtain an independent opinion of the clinical status of the individual. Workers' compensation insurance carriers, auto insurance carriers, and self-insured employers have a legal right to this request. Should the doctor/therapist performing the IME conclude that a patient’s medical condition is not related to a compensatable event, the insurer may deny the claim and refuse payment.
Every state has different laws when it comes to Worker's Compensation and No-Fault claims and every insurance company works differently. In a Massachusetts No-Fault claim the insurance companies may require a report to be dictated by the doctor within 24 hours of the IME and sent to all parties of interest. In New York State, the Worker's Compensation Board allows the doctor 10 business days from the date of the IME to dictate the report and have it sent to all parties. Most often, there is an IME Vendor/Company involved in which they schedule the exams, send out appointment letters, follow up with the doctors, proof read the reports for any errors or missed information, and finally, send out the reports to all parties. The insurance company just makes the request to a preferred IME vendor, and the vendor takes care of the rest.
New York State has some very strict laws when it comes to Worker's Compensation. In some cases, a claimant may have what is called a C-4 Authorization case, which indicates the claimant needs surgery or Physical Therapy. The claimant's treating doctor will send a C-4 Authorization Request to the insurance adjuster. The adjuster then sends a referral to an IME Vendor and requests that per the Worker's Compensation Board, an IME is completed and the report is due back to all parties within 30 days of the treating doctor's request. If a vendor cannot supply a doctor who can book an appointment this soon, a File Review or Records Review may be proposed by the vendor to the insurance company. In this case, the doctor will not see the claimant, but will just review their medical records and dictate a report. The IME Vendor is usually instructed by the insurance company not to tell the claimant they are having a records review.
In New York State, an MG-2 Request is similar in that the IME and report must be completed in 30 days.
A Rocket Docket is a controverted claim, basically meaning that the insurance company is fighting the case. A report must be produced within 90 days of the pre-trial hearing. An insurance company may request that an IME Vendor set up Surveillance on a claimant. Reason being, if the claimant says they have a broken collar bone and the surveillance catches them at the batting cages, now the insurance company can ask the IME doctor to review the footage and medical records, see the claimant and dictate a report. Adjusters have been known in the past to have checked on Facebook to find out what the claimant is doing lately. For example, if PTSD or depression is an alleged claim from an accident, but the claimant is out partying or going on tropical vacations and posting pictures, this could look rather suspicious. The adjuster will then ask that the doctor question the claimant on their hobbies.
All of the above situations are because the insurance company has to pay for a claimant's treatment from an injury. So if a claimant is lying and doesn't require time off, benefits and treatment, the company doesn't want to pay for it. This is why it is always recommended that the claimant be as truthful as possible and attend their IME's. An IME is a second opinion exam. If you are truly injured, the IME doctor will note this in the report and recommend more treatment.
It is most unfortunately true that sometimes, insurance companies do call IME Vendors and request which doctors to use for an exam. "Independent," means non-biased, so this is wrong. However, some doctors fail to answer questions regarding the claimant's disabilities. That is the reason they might request a different doctor than previously used. The IME Vendors receive their business from insurance companies, so they are at the mercy of the adjusters and do everything they can to please them, but they always document when requests are made, so that they have proof that an adjuster has made a request. However, they are instructed never to tell a claimant that a doctor has been requested by an adjuster. Basically, if an IME Vendor does not appease the insurance company, they may stop using that vendor, and if it is a large enough company, it will make a dent and the IME Vendor loses a lot of business.
An IME Vendor should try to schedule an exam within close range of the claimant (some insurance companies prefer within 10 miles, some prefer within 30), but in some cases, a specific type of doctor may not be available that close, so the vendor will ask the adjuster permission to schedule outside of that close range. If the adjuster approves it, the claimant may request transportation by calling the adjuster or the IME Vendor. If transportation is approved the insurance will cover this. If an interpreter is required, the insurance will also cover this. The adjuster or the IME Vendor then has certain companies they order interpretation/transportation through.
When an adjuster needs a New York State IME as quickly as possible due to a hearing or another urgent matter, a waiver can be signed by the claimant or their attorney, waiving their rights to 7 business days' notice of the appointment by mail (which is a law of the WCB). A common question from an IME Vendor, to a claimant or their attorney, may be to sign a waiver form. If the claimant signs this and goes to the appointment, this is okay. However, if an attorney's office refuses to sign it and won't let their client sign it, then the exam will have to be rescheduled to a later date to allow more notice time for the claimant. If a claimant attends the exam and their attorney says they'll sign the waiver, but never provides the signed waiver to the IME Vendor, the report that is dictated by the IME doctor will be precluded (meaning it is not valid because the waiver was never actually signed and returned).