Nervous about having an independent medical exam? You should be. Learn how insurance company doctors can make or break your workers’ compensation claim.
Navigating the workers’ compensation medical process can add even more discomfort to a painful work injury.
Each state has its own rules and regulations regarding workers’ comp claims, but one rule is common to all:
Injured workers seeking benefits must be evaluated and diagnosed by workers’ comp doctors approved by the employer’s insurance company.
For many injured workers, that means facing an Independant Medical Examination, or IME, ordered by the workers’ compensation insurance company.
Can You Be Forced to Have an Independent Medical Exam?
If you’re injured on the job and making a workers’ compensation claim, you must be medically evaluated and treated by doctors who are approved by your employer’s insurance company.
Virtually all state regulations permit you to be treated by your own doctor, but your claim is highly dependent on the medical opinion of the doctor from the insurance company’s approved list.
Several circumstances may cause the insurance company to request that you submit to an Independent Medical Examination (IME).
The insurance company calls it a request, but the hard truth is that if you refuse to undergo the IME, your claim will be flatly denied. Game over.
Remember that the workers’ comp insurance company will do whatever it takes to save money. That means limiting benefits and wage payouts to injured workers like you.
The fastest way for the insurance company to justify limiting your workers’ comp is to have medical “proof” that you’re ready to return to work.
You can expect to be scheduled for an independent medical exam when:
- The insurance company disagrees with your treating physician’s medical opinion.
- The claim is moving too slowly or getting too expensive, and the insurance adjuster wants to close it down.
- Evidence is needed to resolve a dispute about your claim, limit your benefits, or to deny your claim entirely.
And if your treating physician determines you have a total or partial permanent disability, you can bet the insurance company will be sending you for an independent medical exam with their handpicked doctor.
IME Doctors Work for the Insurance Company
Doctors have various reasons for deciding to work for an insurance company, but like most people in the workforce, their goal is a paycheck.
Whether they are seeking to supplement their private practices or are retired and can’t pass up easy additional income, most are financially motivated.
IME Doctor Qualifications
You won’t often find doctors certified in surgery, orthopedics, or other specialties performing medical evaluations for workers’ comp insurance companies. Frequently, doctors primarily handling work accident claims are considered “fringe” doctors.
Many don’t keep up with the latest medical literature, pursue continuing medical education, or stay current in the latest medical technology. Some are general practitioners with limited or no previous experience in workplace injuries.
Workers’ Comp Doctors Protect Company Profits
Workers’ compensation doctors know insurance companies don’t like spending money on expensive tests like MRIs and CT scans. These tests are expensive and complicate the entire claim.
Even when doctors would normally recommend those diagnostic or therapeutic services, in workers’ comp cases, they won’t mention it to the injured worker. It’s easier for the IME doctor to just side-step having to deal with your frustration or a controversy with the insurance company.
As a result, lots of insurance company-approved doctors are more likely to treat injuries with pain medication. Pills are much less expensive than an MRI.
Workers’ comp IME doctors know that if they verify the severity of your injuries, the insurance company will have to pay your benefits accordingly. They also know the insurance company won’t like it.
To remain on the list for workers’ comp referrals, some doctors may classify patients as malingerers, rather than diagnosing real pain issues and injuries with implications for long-term disability.
Workers’ Comp Doctors Don’t Care About You
There is no such thing as a truly independent medical exam. Doctors hired to perform IMEs are paid by the workers’ comp insurance company handling your claim. In most cases, the adjuster working your claim chooses the IME doctor you will be required to see.
Remember, if you refuse to submit to an IME, the insurance company can legally deny your workers’ compensation claim and stop your medical and wage replacement benefits.
The IME Won’t Take Long
The workers’ comp doctor isn’t there to treat you or help you deal with your work-related injuries. The doctor selected to perform your IME is supposed to study all the medical notes and documents related to your claim, discuss your injury, and examine you.
In reality, the examinations are usually very short, some lasting less than ten minutes. Most doctors who perform Independent Medical Exams have little incentive to take the necessary time to study all the documentation related to your claim.
Workers’ comp doctor fees are based on the number of patients, not on the time spent on each case. The more patients pushed through in a day, the faster the fees rack up.
Double-Dipping IME Doctors
Another potential conflict of interest arises when doctors own or have financial connections in the healthcare facilities they are referring you to for diagnostic exams or treatment.
Because of their financial interests, some doctors may order unnecessary or questionable tests or treatments hoping the insurance company will pay for them. Like the doctor who orders custom braces or orthotic shoe inserts that can only be made by a company owned by the doctor.
Should the insurance company consider those tests or devices medically unnecessary, you may be personally responsible for the costs of the tests or other extended treatment.
What To Do Before, During and After an IME
How to Get Ready for an Independent Medical Exam
You can’t refuse the insurance company’s request for an IME or you’ll risk losing all your workers’ comp benefits. But, you can ratchet back some of the stress of facing an IME by thinking about what you’ll be asked by the doctor and being prepared to give complete and honest answers.
If possible, have a friend or relative go with you to the IME. It never hurts to have your own witness to the exam. They won’t be allowed to speak but ask them to take notes.
What are the issues?
The insurance company will send copies of your medical records to the IME doctor well before the scheduled exam date, usually along with a cover letter telling the doctor what they want to know about your condition.
Try to get a copy of that letter. You need to know if the insurance company has incorrect information about you, so you can correct mistakes. Make the request in writing and send a copy of your request to your state’s workers’ comp board.
How did the accident happen?
Review exactly how the accident happened and be prepared to re-tell the details to the IME doctor. Yes, the doctor should have that information from your medical records, but they’ll want to hear it from you.
Take your time. The IME doctor will be looking for inconsistencies in your story, so don’t let anyone rush you. Don’t volunteer your opinions, just relate the facts.
What to Expect During Your IME
You have no right to confidentiality with this medical exam. Everything you say or do will be reported to the insurance company and can be used against you.
You’ll be observed from the time you arrive at the IME location. They’ll be looking to see if you hop easily out of your car and walk briskly to the building, only to limp and groan as you struggle to ease into a chair in the waiting room.
What’s your medical history?
Don’t try to conceal pre-existing conditions. If you’ve got prior injuries or a pre-existing medical condition, be prepared to explain how this work injury and it’s affect on you is different and distinct from your condition before the work injury.
How are you today?
Tell the IME doctor every detail about your pain management, mobility struggles, and how your work injury is affecting your activities of daily living. Don’t exaggerate, but don’t leave anything out.
There may be details that are embarrassing but are impacting the quality of your life. If you haven’t been able to dress yourself since the accident, or sometimes have trouble making it to the bathroom in time, you must speak up.
Remember that insurance companies often have injured workers under surveillance. If you say you can’t drive, lift or bend, you could forfeit your workers’ comp claim if the insurance company has videos of you loading groceries into your car.
Be on time and be careful. Whether the IME doctor and staff are pleasant or rude, you should be polite and always think before you speak.
Do This After an IME
Even if you brought a witness to take notes during the IME, make your own notes about the exam while it’s all fresh in your mind. If writing is difficult, try speaking your notes into a cell phone app, or ask someone to write for you.
Request a copy of the IME doctor’s report. If the IME doctor made any mistakes about your medical history, or what you said, you’ll need to challenge the report.
Be Careful of the Nurse Case Manager
Nurse case managers are registered nurses whose job is to facilitate communication between the doctor and the insurance company. You may have a nurse case manager assigned to help you with your claim.
The nurse may present herself as your advocate who is acting in your best interests. Although most nurses are honest and hard-working, don’t forget that the nurse is employed by the insurance company.
You Have A Right to Medical Privacy
The insurance company nurse may demand to be in the room when your doctor is examining or treating you and won’t hesitate to challenge your doctor’s opinion.
If a nurse threatens to stop your workers’ comp benefits if you won’t let her come to your doctor appointments, immediately contact a personal injury attorney for advice.
In most states, you can refuse to have the nurse in the examination room with you while you are seeing the doctor. Also, you don’t have to speak with the nurse.
With the nurse case manager in the room, anything you say or do during the examination can be used against you. The nurse will report anything you say or do to the insurance company with no regard for your personal privacy.
For example, she may disagree with your doctor about your pain or mobility level and when you should be released to go back to work. In that case, she could recommend that you be sent for an independent medical exam with a different workers’ comp insurance company doctor.
Remember, it’s you against the insurance company, and the nurse case manager is just another of their employees.
How to Protect Your Workers’ Comp Claim
If you are completely satisfied with the level of care and treatment from the workers’ compensation doctor, and the amount and duration of your wage replacement benefits, there’s nothing more you need do.
But if you feel you are being played by the workers’ comp insurance company, or you aren’t sure you’re getting the benefits you deserve, don’t wait to protect your claim.
You have the right to seek a second medical opinion if you feel the workers’ comp doctor isn’t addressing your medical issues. Most insurance companies permit an injured worker to have a second evaluation from another doctor on their approved list.
While second opinions may seem helpful, the other doctors is getting paid by the insurance company, just like the first one.
Ask your attorney how to proceed.
After a specified time from your claim filing, you’ll be permitted to have an evaluation and treatment from a physician you choose, whether on the insurance company’s approved list or not.
Getting a second (and sometimes third) medical opinion can help support your claim.
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