What should you do, as a healthcare provider, if an Independent Medical Examiner determines that a patient’s injuries are resolved, and the insurance carrier issues a denial?
If an IME doctor determines that a patient’s injuries have resolved, the carrier will issue a global denial cutting off further treatment. Once this denial has been issued, the carrier will deny further bills that are submitted, but this does not mean that the provider should stop treating a patient. If a provider feels that a patient’s injuries have not yet resolved and that further treatment is medically necessary, they should continue to treat the patient and pursue reimbursement from the carrier in court or arbitration.
Should you keep treating the patient after an IME denial?
We advise our clients of the following: “You determine medical necessity of treatment, not the insurance doctors or carriers. Just document your findings well throughout treatment.”
When a provider elects to continue to treat a patient post-IME cutoff, it is crucial that there are contemporaneous exams or records that serve to rebut the IME doctor’s report(s). Our practical advice is to do a reevaluation the week before the IME and the week after if possible to document the extent of the patient’s injuries and to rebut the IME doctor’s report findings of resolution or normal where the IME doctor is acting more as an advocate for the carrier than the designated “Independent Medical Examiner”.
When should exams and treatment be performed?
Exams that are performed within a month before or after an IME are extremely valuable because they are used by your lawyer to contradict the findings of an IME doctor and persuade an arbitrator or judge that the treatment was medically necessary.
Thorough, contemporaneous exams that include quantified range of motion restrictions, provocative orthopedic tests, and neurologic testing, will often rebut the findings of an IME exam and establish that treatment was necessary.
Thus, if a provider continues to treat a patient post-IME, re-exams should be performed frequently, and AT MINIMUM on a monthly basis.
What are best practices for submitting bills for treatment after an IME Denial?
After an IME denial of future treatment, bills for treatment should still be submitted to the carrier, as the denials that the no-fault carrier generates will aid in establishing a case at arbitration. A provider may continue to treat a patient as long as they feel the treatment is necessary. Arbitrators will award reimbursement when the medical record clearly indicates that further treatment was warranted, i.e. medically necessary.
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