Policy Guidelines for
Complex Independent Medical Evaluations
In the time allotted for an evaluation (normally one hour) the physician(s):
- Thoroughly review the medical chart, including X-rays, MRI’s, etc.
- Take a detailed history relating to the date/type of injury, type/duration of treatment, the success/failure of treatment, past injuries, medical history, etc.
- Complete a physical examination.
- If a panel evaluation, discuss the case with participating physician(s).
- Dictate a report that encompasses each of the areas mentioned above, and answer all questions posed by the adjuster or nurse case manager or attorney.
Therefore, in order to ensure that physicians have ample time to provide well-prepared and comprehensive evaluation reports that include a discussion of all pertinent issues, the following policy is enacted:
All claims that involve one or more of the following items are considered complex claims and will require a minimum of two (2) hours to complete the review, examination, and report. The following criteria will help define those cases treated as complex claims:
- Two or more unrelated body parts are evaluated (i.e., cervical spine and knee)
- Two or more dates of injury are involved
- The date(s) of injury(ies) is more than twelve months prior to the exam
- The medical records exceed two inches
- An interpreter or videotaping is requested
- A nurse case manager is involved in the management of the claim
- An attorney is involved in the management of the claim
Pre-Approval:
Per physician request, attorney referrals may require submission of written correspondence (prior to scheduling) that outlines the medical issues of the claim, the questions to be posed, and an indication of the volume of the medical record. The requested physician(s) will review the correspondence, advise if they are willing to conduct the evaluation, and will request the amount of time to be reserved. The amount of time needed for attorney referrals may be in excess of two hours.
Cancellation:
All two-plus hour evaluations are subject to a 50% charge if cancelled eleven (11) to fifteen (15) business days prior to the evaluation date and 100% charge if cancelled ten (10) or fewer business days prior to the evaluation date. If a cancellation occurs after this timeframe, every effort will be made to reschedule the physician’s time. However, if the reserved time is not rescheduled, the original referral source will be billed accordingly. In cases where payment is required in advance of the evaluation, there will be a credit or refund for any time that is rescheduled.
