Information provided by Jonathan Javors, DO, Orthopedic Surgeon with Medical Specialists in Munster, Indiana
The Independent Medical Examination (IME) was created by the Indiana State Legislature in 1991 to resolve disputes pertaining to alleged worker injuries. This is part of the State’s Worker Compensation statute (IC 22-3-1-3 and IC22-3-3-7) and falls under the administrative jurisdiction of the Indiana Workers’ Compensation Board. The IME process is coordinated through the Workers’ Compensation Board’s Ombudsmen.
It is important to make the distinction between an Independent Medical Examination and a Medical Examination. A true IME must be administratively arranged and coordinated through the Workers’ Compensation Board.
Often, workers’ compensation examinations are arranged and coordinated by one party of the dispute. These may be arranged and coordinated by the defendant employer, usually by the insurance carrier, or by the plaintiff, usually by the worker’s attorney. These are not truly “Independent Medical Examinations”, as the physician is being hired by one of the parties, and therefore is not “independent.” These truly are Medical Examinations (ME). While the elements of both IMEs and MEs are the very similar, I believe that the Administrative hearing officer needs to review these with that distinction in mind.
That is not to say that an ME cannot be impartial and therefore of no value. Medical Evaluations can often be helpful to the employer and carrier to provide the basis for a work induced causative factor and expedite treatment.
Elements of an Independent Medical Examination
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There are six elements to an IME:
1. Comprehensive history especially of the injured body part in question. A general review of the patient’s past medical history, past surgical history, medications, allergies, vital signs, and review of systems is also included.
2. Comprehensive physical examination of the body part in question
3. Review of diagnostic tests taken to date
4. Review of the medical records generated to date
5. Impression or diagnosis
6. Recommendations
In regards to the medical legal aspect of an IME, the recommendation aspect is the most important element and in it there are four issues to be addressed for the Worker’s Compensation Board. These are listed below and will be discussed in detail.
1. Causation: Did the alleged injury at work cause the patients damages?
2. Maximum Medical Improvement (MMI): Has the patient reached the full expected potential of recovery as a result of the treatment obtained to date or will additional treatment be expected to increase functional activities?
3. Is the patient able to return to full functional activities, can they return to their pre-injury job duties, or are permanent restrictions necessary?
4. Additional information or testing required before the first these issues can be addressed?
Causation
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Quite often, in my experience, this is the most important, and contentious element of the IME. Many injured employees will have had previous injuries, especially when the spine is involved. If there is a fracture, crush injury, laceration, etc., causation is certain. However, when “soft tissue” injuries are claimed, especially if not witnessed, and discovery finds previous problems to the same body point claimed, a fairly straightforward case becomes very muddled.
In these situations, a review of the patient’s history and medical records is paramount. As an example, let’s assume an injured worker, claiming a lower back injury at work, has a history of previous lower back problems. Facts to evaluate are:
• Did the previous problem require on-going or relatively recent treatment, or was it something that was treated years ago and there is no medical record evidence of recent treatment? If on-going treatment has been required, that speaks more for an exacerbation of an on-going problem. Conversely, if no recent treatment was required, this suggests a new injury.
• Are the current symptoms the same as in the past, or are they different? Medical records may reveal an on-going lower back problem with no leg symptoms, while the patient is now complaining of leg symptoms. This suggests new pathology. It is important to review the previous treating physician’s chart records, including history and physical exams.
• If there were prior diagnostic tests taken and these are available, these can prove vital when compared to post injury tests. As an example, if the pre-injury MRI shows degenerative changes and the post-injury injury now shows a herniated disc causing nerve root displacement in the radicular area of the patient’s complaints, this is a substantial material finding and could be considered definitive.
• A review of the medical records from, or about the time of the injury or incident is important. As an example, if the body part you are evaluating for the Board is the lower back, and the medical records indicate that the patient initially was complaining about a neck problem and did not complain of lower back symptoms for weeks or months after the initial injury, causation is brought into question.
Maximum Medical Improvement (MMI)
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“From a reasonable degree of medical and surgical certainty.” This is the standard when determining if additional treatment will improve function.
Too often, it seems that our colleagues forget about this standard when treating these patients. As examples, how can 40 to 50 sessions of physical therapy treatments for a soft tissue injury, and these sessions have done little or nothing to improve the patients function, be deemed reasonable? Conversely, how can medications and therapy be deemed reasonable for a clear cut herniated disc with radicular symptoms? These are fairly typical scenarios in independent examinations.
When determining MMI, the examiner needs to carefully review what the injury is, what the scope of the treatment has been, and if there is any reasonable additional treatment, at the time of the IME would be expected to improve the patient’s function.
Another issue when determining MMI is to consider objective, measurable parameters versus the patient subjective complaints. Subjective complaints are not amendable to treatment. That is not to say that patients do not have subjective complaints. However, these must be verified by a careful check for symptom magnification signs. Pain will most often have companion objective findings. Symptom magnification will not.
This is the area of the IME where the examiner’s repertoire of tests to determine symptom magnification will be important. If these tests suggest magnification, then this suspicion should be noted in the report.
The following points should be specifically addressed in the final report:
• The patient is or is not at MMI.
• If not, the examiner needs to be specific as to what additional treatment is expected to improve the patient’s function, and for how long and what the outcome of this treatment is expected to be. As an example, if the examiner determines that an epidural is reasonable, yet surgery is not, then this should be included. Conversely, if an epidural should be attempted, but if not successful, a microdiscectomy is necessary, then this also needs to be stated.
• If the examiner does not have enough information to make a determination, what needs to be obtained (e.g. additional records)
• If there is a suspicion of symptom magnification, yet the examiner is uncomfortable making that determination with the information at hand, a Functional Capacity Evaluation (FCE) or psychological consult may be in order.
Functional Ability of the Patient
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When determining the functional ability of the patient, this is to be addressed as of the time of the IME. Sometimes this is difficult to determine when pertaining to the patient’s specific job. At the beginning of the history process, the examiner needs to ask the patient what their job title is and what the physical requirements of their job demands.
Sometimes the patient is unclear, or sometimes the patient may embellish their duties. These duties may be determined with a reasonable degree of certainty if the job duties are included with records. However, often these are not.
Sometimes the examiner has a good idea of what the job duties entail by experience or knowledge gained through prolonged interaction through the treatment of injured workers.
What seems to work well is to always list the restrictions and if there are none, then state that in the examiner’s opinion, there are no functional limitations. That way the hearing officer can make the determination.
Another acceptable method is to list specific restrictions, and then add “in the examiner’s opinion, these restrictions do/do not preclude the patient from returning to the job on which they were injured.
Additional Diagnostic Testing
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In this section, if the examiner feels that additional testing is necessary before the IME can be completed or if the examiner has a report on a specific test but needs to review it personally before rendering an opinion, then this needs to be stated. In addition, if the records received do not appear to be complete, then this is the section that this request should be so stated.
As an example, if the patient indicates that he or she underwent a functional capacity evaluation, yet it is not on the chart, this should be noted in the report. Another example is if there are serial MRIs reported by the patient or treating physicians, and these are not included in the record, they need to be obtained. The worker compensation ombudsmen are very helpful in obtaining these. This omission will be included in the record, and a call placed to the ombudsman on the case to expedite procurement of the missing tests.
Often, additional testing is necessary to fairly render an opinion. As with missing records, this is stated and brought to the attention of the ombudsman.
When there are missing records or additional tests are required to make a fair opinion, it is necessary to reserve the right to review these before the IME can be considered complete.
Other Points
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Below are a few other points that could be included in the IME report:
• At the start of the history, the patient should be told that this is an IME, requested by the Workers Compensation Board at their request and that as an independent medical examiner, no patient/physician relationship is formed.
• The patient should know that as an independent medical examiner, no medications will be prescribed.
• The patient should know that the result of the IME will not be discussed with he or she after the examination and that the report will be completed and sent to the Board as soon as completed
• The patient should know that the Workers Compensation Board determines who gets a copy and that the independent medical examiner’s office should not be contacted for any reason by the patient.
• The patient should be told that the independent medical examiner will not be ordering any tests. However, often plain radiographs may be obtained.
• If the independent medical examiner believes that there are any symptom magnification findings, these need to be listed and pointed out in the report.
• It is appropriate to list suspected symptom magnification in the Impression section, if the independent medical examiner has reasonable belief.
• Any reports, videos, and opinions offered by the employer, insurance carrier, or either the employer’s or patient’s legal counsel should be ignored unless the ombudsman approves there use.
