Learn about Independent Medical Exams

Host: When actually you’re getting these benefits, you’re getting your treatment, you’re getting your wages; whatever is involved, and eventually you’re going to get a letter from your trust company Guest: the IME letter Host: The Independent Medical (--) Guest: Yes Host: Why is it that independent? Guest: It’s independent in, the insurance companies don’t necessarily pay the doctors directly, from what I understand, but you are going to a doctor that was set-up by the insurance company, to give you an examination and to create a report which tells the insurance company whether you are entitled to these benefits anymore. So for instance, if you’ve been treating with the chiropractor, they will end you to a chiropractor, or any doctor independent medical examination doctor and that chiropractor will examine you, write a report and say “I feel that this patient doesn’t need anymore treatment or needs treatment for another 4-6 weeks and the insurance company will act on that report; unfortunately, 90% of the time, the IME doctors want that you don’t need any more treatment. Host: Why do you think that is? Guest: Well, I mean there’s different reasons, some doctors feel that you’ve reached maximum benefits, or you reached the maximum potential with this particular doctor, if you’ve been treating for 4 months with the chiropractor and you’ve shown no real improvement, they’re not saying that you’re 100% well, I think what they’re saying is that maybe some other doctor can help you. Host: This treatment hasn’t helped you they say, even taking this medicine for 3 or 4 months, you still are complaining of the same pain, why should we continue to pay for this medicine? Guest: Right Host: Why should they pay for treatment? Guest: So when they deny you, when they say you don’t need this treatment anymore, I don’t think they’re saying you don’t need any treatment anymore, I think they’re saying you don’t need this treatment anymore (--) Host: Hopefully there’s only treatment that you’re getting Guest: Right, usually the client will be Host: Oh, we’re talking about so, what is my soft tissue injury? Guest: Right, although you may see a neurologist, and they’ll send you to a neurological doctor and that doctor will determine whether or not you need continued neurological benefits and you can be denied a chiropractor benefits but not neurological or orthopedic benefits. Host: Or Acupuncture or does that usually go hand to hand with chiropractor Guest: Acupuncture actually usually falls strangely enough under orthopedic, it’s usually physical therapy, acupuncture, orthopedic; but they will send you to an independent doctor for acupuncture as well; but they can’t deny you the category; for instance if you go, if you’re treating with a chiropractor, they can’t deny you orthopedic benefits Host: Right Guest: If you just go see a chiropractor or any doctor Host: So that was the one reason you said that you’re often denied; what’s the other reason? Guest: The other reason is that, unfortunately that they’re saving money for the insurance company basically, I mean, over this process the insurance company is paying these doctors for your treatment and, you know, the insurance company is not going to pay 6, 7, 8 months of chiropractor treatment, they just don’t, they feel that their money can be better spent if you go for other treatment Host: So you think the doctors or some of the doctors that do this IME’s are aware the fact that, what, that they’re supposed to deny future care or that it’s in the best interest of the hand that’s feeding them? Guest: Well, I do think that the independent medical doctor will not get as many independent medical examinations Host: Because they keep the hand that feeds them Guest: Yeah, so I mean, that’s another reason why, it’s a business and I think that the doctors, they want to earn the independent medical examination doctors want to earn their money as well, and they’re not going to do that if they keep giving more treatment Host: Okay, so how about this guy who had this accident, it hurt my neck, it hurt my back, what do chiropractor or neurologist, acupuncturist that got checked out by an orthopedist and how will be siding them, seeing all these doctors for the insurance company; and now all these side I’m getting these letters telling them my benefits have been terminated, they’re not paying for any more treatment, but I still have pain Guest: Right Host: I come to you, my lawyer, and I say, what do we do now? Guest: Usually, my first answer is you should discuss this with your doctor, because the IME report isn’t necessarily the correct decision for you, as awe just discussed there’s other reasons why you may be getting denied, your treating doctor knows you best and if your treating doctor feels that his treatment is going to continue to help you, under the no fault rules, your treating doctor really is supposed to continue to treat you, continue to bill the no faulty company and down the road, either the doctor’s attorney or our firm will arbitrate the doctor’s bills and if an independent arbitrator feels that the denial is incorrect, the insurance company has to pay your doctor, plus interest for the treatment if in denial, that’s the perfect world Host: Perfect world, what happens in an imperfect world? Guest: In imperfect world is the doctor, your treating doctor is afraid that he’s not going to get paid for the treatment that he renders to you and he asks you to put the case on a lean, or the treatment on a lean, or go through your own private if you have private medical, or pay at the pocket Host: So you say put the case, the treatment on a lean, you want, you made the doctors search the lean against that person’s case, my case with my lawyer and then when I get my money for my case, the doctor’s going to collect; and now for some payment for treatment that you rendered after the denial. Now if I settle my case for $50,000 and the doctor gets a $1,000 of my money from this lean, do I have any recourse to further recoup that money from the insurance company? Guest: Well, you can if you show that you paid this doctor, but not through a lean actually, you can’t really through a lean, the lean is an agreement between he doctor, yourself and our firm, or the law firm, and you’re saying that I need more treatment and I will pay the doctor from my case; if you go to your own private, and they can also assert the lean on the case, after denial Host: So UCHI, you’re Oxford or whatever it is Guest: Right, you can show that you paid for treatment through the lean and again, we can arbitrate for that client for Host: For reimburse Guest: To get reimbursed; usually it’s for a higher, it’s not for 5 that a chiropractor visits for (--) Host: Well, it will rule for $1,000 as it’s going to be like that Guest: Yeah, I guess a thousand would be the Host: I mean, sometimes you see somebody has been cut off for treatment and now their doctors tell them they need surgery, let’s say there’s a tear in the knee, the insurance company won’t allow anymore orthopedic care Guest: Right Host: So they go through their private health insurance and now you’ve got a bill for 2, 3, $4,000 for surgery rehab, you see that? Guest: We see it and assuming that your private health carrier will cover it because the general rule again is that, if it’s in a car accident, no fault is the primary insurance, but sometimes once you have the denial, your health coverage will then pick it up after that, so they will pay for the surgery, the doctor will get paid and they will assert to lean meaning, GHI or ETNER, will assert the lean on the case and you will owe that money back to ETA Host: What about people who get denied coming through an SMU to fight the denial right there Guest: Almost impossible; because once the insurance companies have their independent medical examination report, they’re going to stick by it, and you can’t arbitrate decision through denial, you have to arbitrate in monetary value, and to do that, the doctor has to continue to treat, would there be a monetary value and then you arbitrate those bills Host: There’s no appeal? Guest: Not, well, my understanding is not any doctors, there’s really, I mean, you can provide them with more documentation and they will send your documentation to one of their doctors that’s called a pure reveal and their doctor may turn around and say “well, we don’t have all the information Host: Does that happen, where they were missing something or we had some additional information we want them to look at, you know, because let’s face it, a lot of these medical exams that we, you know, we’ve had seen our clients go through, a lot of them have been no more than a few minutes long Guest: Yeah, in fact we’ve had clients say, you know, I was examined for 2 minutes, examined for 5 minutes, the doctor never touched me, and we wind up getting a 4-page report, with arranged emotion results and things that in my opinion cannot be done in 2 or 3 minutes; so I mean, my feeling is that, when you arbitrate these bills, the arbitrators want to fight for the doctors or the client, they don’t necessarily want to fight for the insurance company, but you have to provide enough information to show that the insurance company was wrong to deny you. Host: What’s something that you see doctors doing wrong in their billing practices that hurt their chances of collecting money after denials? Guest: Well, I’ve seen some doctors who, on their daily notes will write same complaint as evolves, same complaints as last time (--) Host: Each day, yes Guest: Everyday is the same thing, same treatment, same complaints, same results; and if that’s the case, you’re probably not going to win an arbitration because you want to do is you want to show an arbitrator that your patient is continuing to improve even after denial Host: Treatment’s helping Guest: Right, I mean, basically what they’re saying in the denial is you reach the maximum benefits and if you can show that they haven’t yet, we used to arbitrate for a chiropractor who would show every few months, range emotion tests, where the range emotion continually improved, and if you ca show that, your arbitrator, almost all the time is going to find in your favor.