Semi Independent Medical Exam

The purpose of this discussion is to delve into the subject of independent medical examinations, commonly referred to as IMEs. An independent medical examination is an evaluation initiated by no-fault insurance companies, which may include entities such as State Farm, Progressive, Liberty Mutual, among others. 

In the event of an accident and the utilization of your no-fault insurance policy, there is a provision therein stipulating that the insurance will cover up to $50,000 in reasonable and necessary medical expenses. Essentially, this means that if the insurance deems the services provided as not reasonably or medically necessary, they have the authority to issue an IME denial, halting the payment of your medical bills.

Now, let’s explore how this process is executed. The insurance company will send you a letter, typically within two to three months after the accident, scheduling an independent medical examination with one of their contracted physicians. These physicians can come from various specialties. 

For instance, if the patient is receiving treatment from chiropractic, physical therapy, orthopedic, neurology, or a spine specialist, independent medical examinations will be scheduled with experts from each respective field. Failure to attend these examinations is considered a violation of the no-fault policy, allowing the insurance company to issue a denial, as attendance is a contractual obligation. Subsequently, the insurance can deny payments for past and future medical services, dating back to the initial bill received.

In practice, it is rare for a claimant involved in a car accident case to skip the IME. However, the term “independent” in independent medical examinations is somewhat misleading. The reality is that these doctors, working on behalf of the insurance companies, often conduct an excessive number of examinations, typically ranging from 50 to 100 in a single day. 

To accomplish this feat, each patient is seen for only one to three minutes. Following these brief visits, the doctors generate comprehensive reports spanning 8 to 15 pages, covering aspects such as range of motion assessments, specific tests like the Neer and Hawkins, comprehensive medical history, and an extensive review of medical records. This intensive reporting, completed within minutes, goes beyond what can reasonably be achieved in such a short time frame.


Why do they go to such lengths?

It is primarily to appease the insurance company. In their IME reports, these physicians conclude, in approximately 95% of cases, that further medical treatment is unnecessary. This conclusion opens the door for the insurance company to issue a denial based on the doctor’s report, asserting that the previously rendered treatment is no longer required, consequently absolving them from further payment. 

This system is inherently disadvantageous to the claimant. As a treating physician, the medical office does not receive payment for services provided to the claimant, who may continue to need treatment.

Additionally, the IME doctor cannot be considered truly independent, given that they conduct these examinations for compensation, typically receiving payments ranging from $500 to $1000 per report. The IME doctor’s interests align with those of the insurance company, as issuing more denials reduces the insurer’s financial burden, ultimately ensuring the doctor’s continued employment.

In essence, the term “independent medical examination” is a misnomer, and it is more aptly referred to as a “defendant’s medical examination” since it serves the interests of the insurance company rather than providing an impartial assessment. 

It is not an independent entity conducting these examinations; it is a company hired by the insurance provider, financially incentivized to produce reports that favor the denial of medical bills. For medical providers offering treatment under a no-fault policy, it is crucial to continue treating patients as long as the treatment is deemed medically necessary. In the event of a denial, the provider can pursue arbitration or litigation to seek payment for their services. 

When it comes to deciding the outcome of such disputes, the weight is likely to favor the treating physician, who has provided care over an extended period, as opposed to the IME doctor, who spent mere minutes with the patient. Moreover, it is vital for orthopedic specialists to continue treatment after a no-fault denial, as surgery is typically considered only after conservative treatments have been exhausted. 

This approach allows for a comprehensive evaluation of the patient’s condition and ensures that surgery is truly the necessary course of action. However, insurance companies are increasingly scheduling IMEs sooner after an accident, creating challenges for providers. Nonetheless, if providers persevere and continue treatment, they can later pursue claims for payment through arbitration or litigation, thus ensuring that patients receive the necessary care. 

The insurance code also mandates that insurance companies pay attorney fees, costs associated with pursuing claims, and interest on wrongfully denied claims, further incentivizing providers to challenge denials. While insurance companies may issue denials in the hope that not all providers will pursue them, providers who advocate for their patients’ needs can ultimately secure just compensation for their services.

In conclusion, it is essential for medical providers to be aware of the complexities surrounding IMEs and to continue treating patients when deemed medically necessary. Pursuing claims through arbitration or litigation is a viable path to securing payment for services provided, benefiting both providers and patients in the long run.