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A Comprehensive Guide on the Utilization Review Process for Independent Medical Exams

Nowadays, it’s common for companies of all sizes to find themselves in the midst of disputes related to accidents in the workplace, personal injury and motor vehicles. It’s also commonplace for health insurers to want a review of a physician’s request for medical treatment.

In order to establish if you have a legitimate claim, it’s important to know all the facts. In some cases, getting to the bottom of the issue in order to settle a claim can be difficult. That’s where taking advantage of your right to have a Utilization Review for the independent medical exam (IME) is a wise course of action.

You may not be familiar with the utilization review process for an independent medical exam, so we would like to go over some background information and the review process, so that you know what to expect and obtain the most valuable results.

Utilization Review ProcessKey Statistics Relating to Workplace Injuries and Motor Vehicle Accidents

Before getting into the nuts and bolts of the Utilization Review Process for Independent Medical Exams, it’s helpful to realize the widespread extent of injuries that could and often do lead to claims and disputes.

Motor vehicle crash

Figures from the Bureau of Labor Statistics state that in 2014, the incidence rate of nonfatal illness and occupational injury resulting in days off work to recuperate was 107.1 cases per 10,000 individuals working full-time.

As far as vehicular accidents go, the Occupational Safety and Highway Administration (OSHA) reports that every five seconds a motor vehicle crash occurs, every 10 seconds someone gets injured, and every 12 minutes a death occurs as a result of a vehicular crash. Many of these collisions occur during the workweek or the daily commute to and from work. This means that employers carry the burden of the cost of injuries.

It’s clear to see that accidents and injuries occurring within the workplace, as well as motor vehicle accidents are highly prevalent. These incidents result in numerous cases of necessary medical treatments, as well as claims and disputes for these treatments.

If you have become involved in an accident or injury claim, the company you have the issue with has the right to ask that you are given an independent medical examination (IME,) as well as employing medical professionals to carry out Utilization Review of your treatment.

What is an Independent Medical Exam (IME)?

An Independent Medical Exam, or IME, is an evaluation of someone who is injured via utilizing a third party independent medical professional who will present a completely unbiased opinion on that said injury.

An IME is particularly useful for you if there is a disagreement about a claim. The process provides the opportunity to get agreement among doctors, attorneys, insurance professionals and employers involved in the case.

When an IME is undertaken, it generally helps to resolve a claim in the quickest and most efficient way, as it clarifies any potential disputes in terms of the degree of damage, illness or injury to a person.

What Is a Utilization Review?

If you’re wondering about the necessity of Utilization Reviews, their purpose is to take a look at the medical treatment a person has received, is currently given or may get in the future, to determine if it is both medically necessary and appropriate.

In some cases, an insurer of a managed care plan may request a Utilization Review after a physician requests treatment approval. In other cases, a patient may request review if they are in disagreement with the insurer’s decision about whether or not a treatment is considered medically necessary.

Upon a review and analysis of medical records, a Utilization Review report outlines the existence of unnecessary medical care, and any pre-existing conditions, injuries, causes and/or evidence of negligence. Insurance companies use these reviews to determine whether a person’s treatment is covered.

There are three main types of evaluations that fall under the Utilization Review umbrella. They are:

  • Retrospective Review: This is a review of treatments that a patient has already received.
  • Prospective Review: This is a review of treatments that a patient is trying to obtain.
  • Concurrent Review: This is a review of treatments that a patient is currently receiving and would like to continue to receive.

The Difference Between a Utilization Review and Utilization Management

It’s very easy to become bogged down and confused when it comes to terminology, so it’s important for you to know what the differences are between a Utilization Review and Utilization Management.

Often the terms “Utilization Review” and “Utilization Management” are used interchangeably, but both phrases have slightly different meanings.

According to URAC, formerly known as the Utilization Review Accreditation Commission, these terms have different meanings.

  • Utilization Review: A Utilization Review is undertaken after health care services have been provided.
  • Utilization Management: Utilization Management evaluates the medical necessity, efficiency and appropriateness of the use of healthcare procedures, facilities and services under the applicable provisions of the health benefits plan.

Even though these terms are often used interchangeably, It is, however, important to know these differences as organizations such as URAC have used specific language to set out their guidelines.

Who Performs a Utilization Review for an Independent Medical Exam?

As you would expect, all IMEs and Utilization Reviews are performed by a third-party, impartial organization qualified to provide medical examinations. These are independent organizations that supply objective medical evaluations for specific workplace accidents, vehicular collisions or personal injury cases just like yours.

The person who performs your IME will:

  • Be aware that the usual confidentiality between a doctor and patient does not apply to your specific situation.
  • Not be responsible for your treatment or long-term health.

IME & long-term health

Why Might You Need a Utilization Review for an Independent Medical Exam conducted?

Utilization Reviews are designed to promote cost-effective health care to patients that includes the most appropriate medical treatments and services for their diagnoses or conditions.

Therefore, if there is work-related injury or accident treatment dispute, and the extent, cause and the medical treatment of an injury need to be clarified, it is important to set the wheels in motion for an IME and a Utilization Review.

A Utilization Review or Utilization Management evaluation will establish whether the injured party actually needs the treatment they are being given, have had or are set to have in the future.

Here are some examples of situations where a Utilization Review for Independent Medical Exams might be needed:

  • The insurance plan refuses to pay for a special medication that the physician ordered because it is not “medically necessary.”
  • The insurance plan refuses the patient go for physical therapy prescribed by the physician.
  • There is a workers’ compensation dispute when an employee suffers an on-the-job eye injury.
  • The insurer refuses to pay for cosmetic breast reconstruction after a mastectomy because it is not considered to be medically necessary.

Carrying out a Utilization Review for Independent Medical Exam is an important opportunity for your company to fully review a request for medical treatment and to ascertain whether your insurance plan provides coverage for these medical services.

What Do Utilization Reviews for IME Determine?

If you are in the position where you need to determine whether certain medical procedures and treatments are necessary, the Utilization Review process can be invaluable. These reviews are considered to be the best way of collating all the relevant information and interpreting everything from the actual cause to the extent.

Your Utilization Review will provide you with the fullest possible picture of your workplace accident, vehicular accident or personal injury case, as well as identify what could be done better or differently.

The aspects of a medical case or claim that a review can identify include:

  • The entire injury history
  • The treatment history
  • Whether or not the accident was the cause of the diagnosis
  • The potential permanency of the injury
  • The maximum possible medical improvement
  • Any inconsistencies in statements or missing medical information
  • Any gaps in treatment
  • Inappropriate referrals for treatment and more

If a company denies coverage after a Utilization Review has been carried out, the claimant is entitled to appeal the decision.

Utilization Review appeal

Types of Utilization Reviews for Independent Medical Exams

There are various different types of Utilization Reviews for Independent Medical Exams. They include those relating to:

  • Personal injury: These types of cases generally relate to product defect accidents, accidents within the home and traffic accidents.
  • Workers’ Compensation: When you suffer from job-related sickness or injury and you’re looking to claim for reparations or reimbursement, you’ll be involved in a workers’ compensation claim.
  • Liability Injury. This relates to suffering and injury on someone else’s property and deeming them liable in terms of compensation. Liability injuries can range from falling over something at work to coming down with a case of food poisoning at a restaurant.
  • Disability Claims. These need to be backed up with at least one-year’s worth of medical records.
  • Occupational Danger Claims. It is the responsibility of your employer to provide you with a safe and healthy place to work. If this isn’t so, it can lead to occupational danger claims.
  • Environmental Hazard Claims: This can cover health issues that transpire from chemical spills, toxic waste and more.

How Do You Prepare for a Utilization Review Process for an IME?

The most important way to prepare for a Utilization Review Process for an IME is to know that the Utilization Process is generally a standard part of a claim, so it’s important not to take anything personally.

As a patient going through a Utilization Review, it’s only natural to feel worried when you’re preparing for the process. You may feel that no one will believe you about your health issues or that you won’t get the treatment you need. This is far from the truth, and rather than being something that is negative, the process is positive for everyone involved.

It’s important to remember that the medical professionals who are reviewing your case will be highly regarded independent practitioners and not your own physician. They will be able to look objectively at your case and will generally be very experienced in these matters.

How to Choose a Facility to Perform a Utilization Review for an IME

When you’re deciding on choosing a facility to perform a Utilization Review from IME, it’s important to find one that is a credible source. The Utilization Review will have an important effect on the outcome and resolution of the case, so seeking out the services of a responsible facility with an impeccable reputation is a “must.”

Utilization Review resolution

When choosing the right facility to perform a Utilization Review for an IME, ensure that they have the following:

  • Accredited medical personnel.
  • An impeccable reputation.
  • The ability to collate the medical files for the consulting physician in advance.
  • The capability to rapidly schedule an appointment as well as communicate with all involved parties with regards to the review.
  • The ability for testimony at depositions and also in the courtroom.
  • The capacity to provide a direct line of communication to all parties.
  • The ability to publish a full and detailed final report that involves issues including work limitations, disability and return to work status.
  • HIPPA compliancy.

Why Choose the IME Care Center for Utilization Reviews For Independent Medical Exams

The IME Care Center is an independent medical examination company that offers all of our clients a full and thorough service throughout the Camp Hill and Carlisle, PA regions and beyond.

We are also a leading provider of comprehensive and unbiased Utilization Reviews. Our service is comprehensive and worry-free, and you’ll benefit from our fully-customized and prompt attention.

Our wealth of resources can help expedite the claims process cost effectively and efficiently. We are always on hand to support you throughout the entire process, so contact us today and let us know how our professionals can help you.

If you are an employer or other professional seeking a thorough and objective Utilization Review, you know you are in the safest and most professional of hands here at the IME Care Center, as we offer:

  • Qualified and experienced evaluators who have extensive experience, resulting in higher-quality information and reports.
  • Board-certified experts in their chosen specialty.
  • A full range of related services such as filling out forms and offering medical depositions. Being able to work with the same provider throughout a claim process is invaluable, as we ensure each step is as stress-free as possible.
  • Detailed reports, containing impartial recommendations and supporting information, turned around within short timescales.
  • A fast and tailored service that doesn’t result in costly delays.

We also offer a full range of services from the simplest of cases to the most complicated, and we pride ourselves on our clear and prompt communications throughout every stage of the process. We offer:

  • Supportive Customer Service: Every one of our clients receives world-class customer service and scheduling to rapidly resolve any outstanding issues. We communicate with you on a constant basis to ensure the quick resolution and closure of each case.
  • Board-Certified Physicians: All of our medical professionals are board-certified experts in their chosen field of expertise. The IME Care Center provides you with access to licensed professionals in the fields of pediatric orthopedics, orthopedics pain management, general surgery, cardiology, ophthalmology, neurology, occupational medicine and more.
  • Independent Medical Exams: We present objective, thorough and detailed Independent Medical Examinations and Utilization Reviews. We also offer the assurance that our professional physicians will remain unbiased and neutral at all times.
  • Medical Record Reviews: Our certified medical professionals are highly experienced in evaluating the medical status of all claimants based on their medical records.
  • Utilization Review Reports: We carry out in-depth and careful reviews of all relevant medical reports as part of our Utilization Review process. This enables us to deliver an objective report.
  • Impairment Rating Evaluation (IRE): An evaluation to determine whether an employee is justified to receive all of the benefits and compensation he is entitled to.
  • Oral/Video Depositions: As these are pivotal in all cases, our team of credible board-certified physicians will undertake sworn testimony to objectively discuss the medical status of all claimants.
  • Resolution of Cold Cases: If you have some old cold cases piling up, we can act as your detectives, resolving them in as timely as manner as possible.
  • Help with Form Completion: When injury situations are contested, it can mean that a great deal of detailed and specialist forms begin to pile up. Let us use our in-depth knowledge to help you ascertain which forms are necessary to your case. We can also complete these for you.

It can be difficult to navigate the many aspects of preparing a Utilization Review.  Our staff at the IME Care Center has an unspoiled reputation for excellence in our field and can walk you through the process. Our team of board-certified doctors will offer you a detailed and unbiased review when you need it.

Contact us at the IME Care Center now for your Utilization Review or other independent medical evaluation needs.