No-Fault: Independent Medical Exam
The purpose of this discussion is to go over independent medical examinations. It is also known as an IME. An independent medical examination is an examination set up by no-fault insurance companies that could be State Farm, Progressive, Liberty Mutual, and the list goes on and on.
Anytime you are involved in an accident and your no-fault insurance policy, there is a provision in there that says that the car insurance will pay up to $50,000 in reasonable and necessary medical expenses, and what that means essentially is that if they determine that the services provided are not reasonably and medically necessary, then they can issue an IME denial, and stop paying your medical bills.
Let’s go over how they accomplish this. The insurance company will send you a letter, typically two to three months after the accident scheduling an independent medical examination with one of their own doctors, and it could be of various specialties. For example, if the patient is treating with chiropractic, physical therapy, orthopedic, neurology, or a spine specialist, they will schedule independent medical examinations for each type of specialty, and then you will be required to appear at each of these examinations.
Otherwise, it is a violation of the no-fault policy, which means that they can issue a denial, as you are required to appear and contractually. The insurance can then deny payments for medical services in the future and even go back to the first bill received. So it is rarely possible in a car accident case of a claimant that they do not appear at the IME.
The IME physician essentially concludes 95% of the time that no further medical treatment is necessary, whether it would be physical therapy, chiropractic, orthopedic, spine, neurology, or any other specialty, even acupuncture. By issuing this report after examining the claimant, they gave the insurance company the right to issue a denial based on a doctor’s report that finds that medical necessity for treatment rendered is no longer necessary and they do not have to pay for medically necessary treatment.
The physician may or may not decide to continue to treat the patient. Physicians may continue to treat if they feel that the treatment is medically necessary. They may also decide to perform surgeries if deemed medically necessary. In case surgery is needed, the place of surgery shall also need to be ready to arbitrate or litigate to get paid. The medical bills can then be arbitrated or litigated and they get paid when the case settles.
The physician would like to exhaust every non-operative management available and usually, surgery is the last resort unless it is on an emergency basis. Typically, a physician will require four to six weeks of conservative physical therapy to come to a conclusion as to whether the symptoms are improving or getting worse.
Most physical therapists, chiropractors, and other orthopedics and specialties that take no-fault insurance and treat car accident victims will continue to treat the patient even after the IME denial and once your treatment has concluded, you put all your bills together, and you go into arbitration and litigation on one filing or multiple filings, and you go and establish medical necessity, and get paid for everything that you have done.
The no-fault insurance code provides the attorney fees that are going to be paid by the insurance company if they issue a wrongful denial. Additionally, they are required to pay the cost of pursuing these actions against them, and more importantly, they have to pay interest on these claims if they are wrongfully denied.