"Independent" Medical Evaluations

Ok, so I think I am going to do a few entries related to consumer advocacy, in order to make the public aware of some things that go on inside the system. The first topic of interest has to do with what insurance companies refer to as "Independent Medical Evaluations" or IMEs. Here's how it works. Let us say that one day while you are at work, you lift something too heavy and tear a muscle in your shoulder and strain your back. You go to your own doctor and he says you need surgery and will need to remain out of work until you have healed appropriately. You have the surgery, but you still don't feel that your arm is quite right and you still have moderate to severe back pain. Your personal doctor continues to write out of work notes and in the mean time, you receive workers compensation benefits.

At first, workers compensation insurance is supportive but the longer you remain on disability, the more they have to pay out, and the more likely they are to pressure you to return to work or try to show you are not as disabled as you say you are because then they can cut off your benefits. How do I know this? Because I hear patient after patient tell me this same story with different diagnoses and we have had the insurance representatives call and accuse patients of faking. To be sure, there are people who try to take advantage of the system and the insurance industry in hyper-alert about this. As a result though, a few bad apples spoil the bunch and those with legitimate injuries get stigmatized as fakers. So here is where IMEs come in.

The insurance companies contract with certain doctors who will perform and IME. These evaluations are different because there is no doctor-patient relationship. The doctor is not there to treat you and does not even have to share the results of the evaluation with you. In an ideal world, the main job of the IME doctor is to come to an objective conclusion as to whether the patient has a specific condition, whether it is related to a specific cause (e.g., an injury at work), and various other questions (e.g., whether the patient has fully recovered, whether the patient can go back to work, etc). Although there are plenty of IME doctors who can do such an evaluation with honor and integrity, the system is ripe with corruption for one main reason: the insurance company is the one paying the doctor.

So let's think about what this means for a minute for the doctor. It means a guaranteed paycheck for services rendered and no need to hassle with insurance claims. It also means that if the doctor does not find what the insurance company wants the majority of the time that the insurance company will stop referring cases to them. Therefore, there is an inherent pressure to find what the paying source wants found (e.g., that the patient is not disabled). The next blog entry will continue this topic some more, discuss some of the practical implications, and tell you what you can do about it.