Worker’s Compensation IMEs
C. Donald Williams, MD CGP
Introduction
Industrial insurance was instituted to protect workers from the devastating
impact of workplace injuries, by ensuring that they would receive medical care
as well as some degree of financial support, typically 60-67% of their wages,
while recovering to the point that they could return to work.
In return for this coverage, the employers are protected against all
lawsuits related to the injuries, i.e. negligence claims.
Determining what medical conditions are causally related to specific
industrial injuries and determining what medical treatment is appropriate is the
province of Independent Medical Evaluations (IME’s).
This essay
will describe the guidelines I have found to be most helpful in the development
of my practice of providing Psychiatric IME’s in Worker’s Compensation
claims. The practices outlined
serve several purposes:
·
Understanding the assignment
·
Negotiating the terms of the evaluation to ensure that the
evaluator and the referral source are in agreement with the extent and cost of
the assessment.
·
Determining whether the evaluation will require testimony or
deposition
·
Practice management guidelines that ensure timeliness and
efficiency in report production
Understanding the assignment
The client may be an attorney, an insurance company, or a state agency.
It is a good practice to require an assignment letter, outlining the
issues that must be addressed. The
assignment letter typically is between two and four pages long, and it may or
may not include a summary of the history of the case.
It is customary for the client to specify 6-8 requirements that must be
satisfied, including questions that must be addressed in the report.
Typical examples are outlined in the table.
Negotiating the terms of the Evaluation
The client should be prepared, in general terms, for the anticipated cost of the
evaluation and report. Fees in the Worker’s Compensation arena, including the
patient evaluation, that exceed $1200 are only rarely cost effective for
clients. Typical charges for a
10--15 page report and evaluation would be in the $500-750 range.
It is important to understand the goals and objectives of the client, so
that time is not expended (and billed for) that is unproductive.
It is wise to require a 7-day notice of cancellation for hearing testimony and
depositions, with a full retainer requirement for new clients.
A sample retention letter is included for reference.
Court testimony and depositions
Determine whether hearing testimony based on the evaluation is expected.
When testimony may be required, the written evaluation should include an
exhaustive recitation of the medical records to date, including relevant
portions of non-psychiatric medical records and reports as well as records
generated by mental health professionals. This
practice is crucial to establishing credibility as an expert witness, and
provides an understanding of the development of symptoms of depression, anxiety,
and pain complaints. It also provides an opportunity to spot discrepancies in
the history provided by subsequent evaluators.
In other words, always do own your research with access to original source
material. It is commonplace to
discover errors in quotation that are perpetuated by a failure to examine
primary records. These include
initial accident reports, progress notes, as well as laboratory and imaging
studies.
Examine the records for contradictions and inconsistencies.
Scrutinize records for bias—the absence of a neutral professional tone.
Work to maintain neutrality in your own review.
The purpose of your evaluation is to determine the truth of the matter,
not to be an advocate. Determinations
of causality are key in worker’s compensation cases, as responsibility for
medical care, disability payments, and time-loss payments ride on those
determinations.
Utilize the DSM-IV, and adhere closely to the formal criteria. Think of telling
a story about the subject, as if you were a novelist.
Your task is to present the developmental history and to describe events
and the impact they have on personality development and function.
Real life is complex, so if you find cliches in your writing, take
another look at the facts and your interpretation of them.
State which diagnoses existed prior to the injury, which were aggravated by the
injury, and which are causally related to the injury. Support your conclusions
by facts and reasoning—they cannot simply be opinion and prevail.
When giving testimony you will
be ask
ed for the basis of your opinion, and
how you
arrived at your conclusion.
The hearing judge evaluates the quality of testimony—examining it for
weakness in reasoning, including lack of foundation.
An effective practice is to consider alternative conclusions, and to
explain specifically why you selected one over another. As your report quality improves, and your testimony becomes
more coherent and fact based, the cross examination will become briefer.
Remember that you are a seeker of truth, and not an advocate.
All parties benefit from competent expert opinion.
Not only is it unprofessional to shade findings according to the
contracting party, it also makes the legal process less efficient, because it
fosters unnecessary litigation. Consider
the impact of an expert providing a biased opinion in a case that persuades a
client to litigate. The matter will
be taken to trial, with all the attendant expense, but the result most likely
will be a finding for the opposition. The
client has devoted considerable time, effort, and expense in a doomed cause,
unnecessarily. There is little
likelihood that the expert will be retained in the future.
Practice Management Guidelines
It helps to have support staff, and it is essential if the goal is to
produce significant numbers of quality reports efficiently.
Scenarios of practices at three different stages of development
1) You are starting out in practice, consult to an agency part time and do 15-20
hours per week of psychotherapy in your new office practice.
You handle calls with an answering service and a cell phone.
You do your own scheduling. You
contract out the posting of accounts and bookkeeping.
You type your own referral letters on your laptop.
This works fairly well, because you can use open hours to handle the
paperwork, and it keeps it simple, except for the hassles with managed care.
2) You have been in practice for a little longer, and conduct 35-45 hours of
direct patient care per week. If
you are in a clinic, billing and scheduling are handled for you.
If you are in solo practice, you probably have someone to answer the
phone in addition to an answering service, and have someone post accounts,
collect money, and send out statements. (If
you do the clerical work yourself, you are putting in at least an additional
10-15 hours per week, making for a brutal schedule, and getting paid about $15
an hour for the pleasure. Let us
assume you have mastered your masochistic tendencies, and have paid help.)
For transcription, you may have retained a contract typing service,
particularly if you are sending many letters to referral sources, and of
necessity if you are dictating your case notes.
If your office person is versatile and energetic, they may handle the
transcription in addition to the billing, but it is a stretch, and they are
likely to burn out.
3) You already have a busy full time practice.
You become interested in performing IME’s privately, and are willing to
provide depositions and testify at hearings.
The IME’s require a review of 3-5 inches of disorganized medical
records, sent to you by an attorney bound together by two heavy rubber bands.
The files are out of order, and there are often two or three duplications
of individual records, i.e. photocopies of original records, and then
photocopies of the same records off microfiche.
Your choices
a) You can sort through the records and organize them yourself—which will take
2-3 additional hours. Question: how
are you going to bill for that time?
b) You can ask you solo office help to do that—she/he can
do it occasionally, but not on a routine basis because they are already busy
with other tasks.
c) You can hire additional part-time help to manage this
and other lower level office filing functions.
The best choice may shift from “a” to “c” over time as your practice
matures. For the new practitioner,
choice “a” may be most cost effective and appropriate—at least for a time.
However, if evaluations and IME’s become a significant part of your
practice (and why do them otherwise?) additional office help will prove to be
essential. Your staff should book
the evaluation, and ensure that records are received in time to organize them in
a three ring binder with a table of contents.
You will then be prepared to conduct the interview, and then dictate the
report within two days and send it to transcription.
I suggest two days, because the material is fresher, and it is easier to
be efficient with the dictation. At
an intermediate practice stage, choice “b” may be the correct one.
Your single office staff person can help with the organization of the
records, but you will have to utilize commercial transcription services.
For the fully developed practice, choice “c” is the best and only
choice. You will require on-site
transcription, in addition to the office-manager.
If the transcriptionist is full time, they may have their duties split
between file organization, general file maintenance, and transcription.
Worker’s Compensation evaluations undertaken for the purpose of litigation are
significantly more complex than those that are simply consultations for
treatment purposes. This complexity
arises from the need to comprehensively review the development of the diagnosed
mental health conditions with the aim of establishing whether the conditions
pre-exist the injury, are aggravated by the injury, or are causally related to
the injury. To accomplish this
requires a comprehensive, verbatim review of the history and a specific
consideration of alternative hypotheses. It
is usually necessary to account for the impact of trait disturbances or
personality disorders on Axis 2, because of their interplay with the injury.
Presumed Axis 2 disorders often appear more severe when accompanied by
Axis 1 conditions—something often overlooked in psychiatric evaluations, but a
factor about which the DSM-IV offers cautions.
In order to provide obviously superior work at a cost that is feasible for the
client, practices that emphasize efficiency are mandatory.
Keeping a time card logged to the minute is a good practice, because it
provides a basis for rational billing and serves as a self-management feedback
tool. Over the last 12 months my
time required for report production that incorporates a discussion of causality
and record review has ranged between 35 minutes and 225 minutes, with the
average/typical report requiring 70-100 minutes.
By contrast, the first time I undertook a comprehensive IME in which I arranged all
the material it took 7 hours. The compression of time now required for the
same amount of work represents improved efficiency.
