medical necessity reviews for workers comp

[painfre]

I know some of Physicians here work as insurance reviewers. I got an offer to do independent medical necessity reviews for workers comp cases. I do not have prior experience in doing these but I can get trained online. I am currently working as Pain physician for 4 days a week at VA hosp in Texas. I am thinking of working as a reviewer for about 8-10 hrs a week. In the state of Texas, since there is no direct doctor-patient relationship , no malpractice can occur. Am I correct? Do I need to get any coverage from Insurance company. Currently, I do not carry any liability insurance. Thanks

---

Members don't see this ad.

 

[bkpa2med]

Correct. Independent medical examinations don't require coverage either. You always start those conversations with - "I am not your treating physician."

 

[freddydpt]

I'm curious. Is this lucrative to supplement practice income? You can PM me if you don't want to respond publicly. Thanks!

 

[emd123]

What if the conversation goes like this every single time?


Doctor-"Sorry, you're not completely disabled. You can do some form of work."

Patient- "My back hurts too much, I can't bend, lift or do ANYTHING!"

Doctor- "This is not an 'own occupation' disability policy. Of course you can do some type of work."

Patient- "I can't stand! I hurt too much."

Doctor- "You can do seated work."

Patient-"I can't sit, it hurts too much!"

Doctor-"You can get a reclining chair and answer phones with a blue tooth head set, lying down if needed. I know C5 quads that do this."

Patient- "I can't lay down! It hurts too much, so I have to get up, and move around, or change position."

Doctor- "Right. Clearly in your current non-working day, you spend at least 8 hours doing some combination of sitting, standing or reclining, albeit not necessarily involving heavy lifting, bending or twisting. So what do you do when you're at home not working, if you can sit, stand, walk or lay down?"

Patient-??????????? (Puzzled look of righteous indignation)

Doctor- "Some form of work is good for chronic pain patients, mentally, physically as well as socially."

Patient- "Can't you just sign the damn form doc?!"

 

[bkpa2med]

What if the conversation goes like this every single time?


Doctor-"Sorry, you're not completely disabled. You can do some form of work."

Patient- "My back hurts too much, I can't bend, lift or do ANYTHING!"

Doctor- "This is not an 'own occupation' disability policy. Of course you can do some type of work."

Patient- "I can't stand! I hurt too much."

Doctor- "You can do seated work."

Patient-"I can't sit, it hurts too much!"

Doctor-"You can get a reclining chair and answer phones with a blue tooth head set, lying down if needed. I know C5 quads that do this."

Patient- "I can't lay down! It hurts too much, so I have to get up, and move around, or change position."

Doctor- "Right. Clearly in your current non-working day, you spend at least 8 hours doing some combination of sitting, standing or reclining, albeit not necessarily involving heavy lifting, bending or twisting. So what do you do when you're at home not working, if you can sit, stand, walk or lay down?"

Patient-??????????? (Puzzled look of righteous indignation)

Doctor- "Some form of work is good for chronic pain patients, mentally, physically as well as socially."

Patient- "Can't you just sign the damn form doc?!"

That is the conversation if you are the treating provider. I've never told people my thoughts at the end of an IME, it's just in the report. Also, the utilization reviews are basically just looking through charts.

What you quoted is quite comical but sadly true. Just like when people fill out the questionaire - Sit for 10 minutes and stand for 5 minutes before I need to sit. It seems as if it is an endless cycle but you never see them alternate sit to stand in the waiting room because you know they've been there for 30 minutes.

 

[Ducttape]

now this is my personal opinion...

but dont sell out and become an IME. the problem is that IMEs tend to identify with whoever is paying them, and it is not the patient. its hard to separate appropriate care when the comp carrier is looking for cost saving measures and paying a physician to find these. i know they will cloak the IME as "we want appropriate care for the patient", but it is not. for most IMEs, it is about satisfying the carrier in not paying for any care, even if the care falls with established guidelines - including previously established state mandated ones - that they will quote back ad infinitum when it serves their purpose alone.

also, there are IMEs that are clearly not competent, and there is little to no recourse for the patient and pain physician to complain, outside of the patient's attorney. (for example, any IME that declares a patient does not have CRPS needs to know what the diagnostic criteria are, and when they ask why you keep talking about a European city, all the while calling it RSD, it borders on nefarious.)

i agree with some of the concerns brought up by IMEs, particularly with trying to get people back to work. but some of the assessments i have seen from IMEs border on clear money grabs from the WC carrier.

 

[ampaphb]

In Louisiana, evaluations funded by the carrier are called Second Medical Opinions (SMOs). These are bought and paid for by the employers, and rarely find anything wrong with the patient.

Independent Medical Examinations are ordered by Office of Workers Compensation. They function as the tie breaker, and are legit. Courts give them a high degree of deference.

 

[Ducttape]

http://www.courts.state.ny.us/reporter/webdocs/NYCOSH_Independent_Medical_Examinations.htm

The first thing to know about a so-called Independent Medical Examination (IME) is that it is neither independent nor a bona-fide medical examination. Although IMEs purport to be independent, it is apparent from the pattern of behavior and the relationship of IME doctors to insurance carriers that this is not the case. The IME itself is conducted by a doctor who has been hired by a workers' compensation insurance company, a "self-insured" employer (a company providing its own workers' compensation insurance) or the New York State Insurance Fund -- parties with a financial interest in minimizing the extent of injuries and illnesses suffered by workers.

The IME is nothing like a medical exam. According to interviews with injured workers and occupational health physicians, the typical IME is vastly different than the type of thorough examination needed to provide a sound basis for important decisions about wage-replacement benefits and medical treatment for injured and sick workers. Exams are generally limited to:

• completion of a medical-history form by the claimant;
• a review of available documents provided by the worker's ("treating") physician;
• a brief medical exam during which the IME physician asks questions about symptoms, treatment previously received, whether the medical condition is improving and, in some cases, during which the IME physician may perform a limited physical exam;
• and the recording of impressions, either in writing or on tape-recorder, regarding the extent of injury or illness, the extent of disability, and what treatment, if any, is called for.

The IMEs ostensibly provide insurance carriers with their own "independent" medical evaluations of workers' compensation claimants. In other words, the exams address whether or not the injured or sick worker is as disabled as the injured workers' doctor says and whether the worker needs ongoing care. But according to one attorney familiar with the system, most IME doctors will only be rehired by insurance carriers if they consistently disagree with the evaluation of the treating physician.

IMEs are also used to make determinations utilized by insurance carriers in connection with paying medical bills and settling, arbitrating and litigating claims over wage-replacement benefits, addressing questions such as What is the final degree of disability? In addition, IMEs are intended as a safeguard against fraudulent suits, or claims without merit. In other words, is this claim valid and genuine?

The IME is not intended to provide injured and sick workers with medical treatment or to give medical advice. Indeed, workers can refuse medical advice from the doctor.

fyi i did not add the emphasis/bold lettering.

 

[pastafan]

IMO, it is not always so black and white. I have reviewed cases such as my last one where a "pain doctor" is billing comp $7,000 per month for various office pharmacy dispensed medication, computer psych testing, series of trigger point injections, etc. all while missing the treatment that I believe would control the patient's pain. It was a PIA reviewing all of the records but after a decade of questionable care without improvement I hope that they will follow my recommendations and get her the care that she needs.