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Jennifer Christian

Abstract

Patients and their advocates tend to be skeptical about reports produced by independent medical evaluators (IMEs) and file reviewers. There are legitimate reasons for this skepticism, but the author points out two common but erroneous beliefs that create unnecessary distrust in disability benefits and workers’ compensation claim management systems. First, despite patients’ faith in their own doctors, treating physicians as a group are not a reliable source of accurate and unbiased information. Second, although justice attempts to be even-handed, impartial physicians should not find for both sides equally (ie, should not attempt to achieve parity in outcomes), particularly because any case sent for review has some feature that raised questions in the mind of an experienced observer. This experienced observer requires an impartial, expert physician advisor who can confirm that the treating physician is doing the right thing or validate the claims manager's concerns. When claims or case managers are doing a good job of selecting cases for referral, one should expect that most of their decisions will favor the insurer/defense. The more expert the claims/case managers are, the more likely the independent physicians will agree because the claims/case managers are accurately detecting real problems and concerns. In counseling their patients, physicians should not discredit the work of independent experts; doing so increases distrust, resentment, and anger and encourages passivity rather than problem-solving.

in AMA Guides® Newsletter
Jennifer Christian

Abstract

The author considers the hypothetical case of a worker disabled by an accident and spine fusion surgery that did not relieve the pain; he is offered opioids and spends his time in a recliner grieving the loss of his self-respect as a good husband, provider, and father. This outcome need not have been a foregone conclusion. Research has shown that, for adults, worklessness is harmful to both physical and mental health, as well as to marital, family, social, and economic well-being. Gaps in social fabric are creating job loss and work disability because none of the professionals who typically respond to workers with job disruption due to illness or injury specifically feels responsible for avoiding job loss. Besides being a personal catastrophe, health-related withdrawal from work (work disability) negatively effects society; the lost productivity of workers in the local and national economy, which accounts for the majority of the approximately $400 billion that federal and state governments spend to support working-age people with disabilities. All Americans deserve timely assistance to maintain their economic independence and enjoy the dignity that comes with having a job. Improved public policy, governmental efforts, and support from the private sector is needed to prevent needless disability.

in AMA Guides® Newsletter
Jennifer Christian
,
David Siktberg
,
Christopher R. Brigham
, and
Charles N. Brooks

Abstract

Independent medical evaluations (IMEs) are widely—and often, inappropriately—used in the claims management process. An IME includes a review of all pertinent medical records; an interview (history) and physical examination; a review of laboratory results and test results; and an edited and signed written report. The primary value of an IME is the report, because a credible medical opinion obtained at the right time can provide information necessary to initiate appropriate action in claims management, both for insurers, who will have a solid basis for acceptance or denial of a claim, and for claimant attorneys, who may use the evaluation to gain acceptance of a claim. A list of common problems in IMEs shows issues about which evaluators should be particularly careful, including questions of use, timing, choice of examiner, adequacy of questions asked and information received, expectations not defined, and framing the evaluation in a negative manner. From a client perspective, IMEs can be improved in several ways, and physicians should understand these opportunities for improving the quality, effectiveness, and value of evaluations. Because referral letters sometimes fail to ask detailed, focused, and probing questions, examiners who have any doubt about the conduct or objectives of the IME should contact the referral source. Detailed checklists and specifications can help ensure completeness and compliance. The article includes a box with definitions of frequently used IME terminology.

in AMA Guides® Newsletter