Workers’ compensation claims don’t always move forward in a straight line.
A treating physician may recommend surgery, but questions may remain about whether it is necessary. Recovery may stall without a clear explanation. There may be disagreement about medical causation. In other cases, the next step simply isn’t clear.
When that happens, additional medical expertise can help.
Traditionally, the response to clinical uncertainty has often been to request an Independent Medical Examination (IME). An IME remains an important tool in workers’ compensation, especially when an independent physical examination is needed. But not every medical question requires an exam. Sometimes the medical records and imaging contain enough information for an expert to provide meaningful direction. Other claims may benefit from a conversation between physicians. The most complicated cases may require input from several specialists.
The key is knowing what question needs to be answered before deciding how to answer it. Start With the Question, Not the Type of Medical Review. Before ordering an expert medical review, identify what is preventing the claim from moving forward.
For example:
- Is there uncertainty about medical causation?
- Is a proposed surgery clinically appropriate?
- Does the imaging support the reported injury?
- Has the injured worker reached maximum medical improvement (MMI)?
- Is an independent assessment of current function needed?
- Do the treating physicians disagree about what should happen next?
These questions don’t necessarily require the same type of review. Defining the issue first can help carriers, TPAs, adjusters, employers, and case managers select both the right review format and the right medical expert.
The goal isn’t to add another opinion to the file. It is to resolve the specific clinical uncertainty that is holding up the claim.
Medical Record Review: When the Evidence Is Already There
Sometimes the information needed to answer a clinical question is already in the medical record. In these cases, an expert medical record review can allow a subspecialist to evaluate the existing evidence without requiring another physical examination. The physician can review the medical history and prior treatment while also evaluating relevant diagnostic imaging. From there, the specialist can address the specific question being asked.
A record review may be useful when questions involve:
- Diagnosis or medical causation
- Medical necessity
- Treatment or surgical appropriateness
- Prognosis
This approach can be particularly valuable when the issue is one of clinical interpretation rather than current physical function. If the question cannot be answered without examining the injured worker, however, an IME may be the better choice.
Independent Medical Examination: When a Physical Exam Is Important
The primary difference between a record review and an Independent Medical Examination is straightforward: the IME includes an independent physical examination. That examination can provide important information when the current condition of the injured worker is central to the question being asked.
For example, an IME may be appropriate when evaluating current functional status or work capacity. It may also be useful when determining maximum medical improvement or impairment. An examination can help when reported symptoms need to be compared with objective clinical findings.
The physician performing the examination matters, too. A complex orthopedic claim may require more than a general orthopedic evaluation. Matching the examiner’s expertise to the condition can make the resulting opinion more useful to everyone involved in the claim.
Peer-to-Peer Review: When Physicians Need to Talk
Not every medical disagreement needs to become a formal independent examination. Sometimes the missing piece is a direct conversation. A peer-to-peer medical review allows an independent physician to speak with the treating provider about the diagnosis or treatment plan. It can also provide an opportunity to better understand the reasoning behind a proposed procedure.
This can be helpful when the written medical record doesn’t fully explain why a particular treatment is being recommended. Rather than making assumptions based on incomplete documentation, the physicians can discuss the clinical reasoning directly. That conversation may uncover missing information or clarify why their perspectives differ. The result may be a clearer path forward without adding another examination to the claim.
Multidisciplinary Medical Review: When One Perspective Isn’t Enough
Some workers’ compensation claims are too complex for a single specialty or medical opinion. These cases may involve previous surgeries or several competing diagnoses. There may also be disagreement about causation or uncertainty surrounding a major treatment decision.
A multidisciplinary medical review or physician roundtable, like BICMD offers can bring relevant specialists together to evaluate the case. Instead of reviewing each medical opinion in isolation, physicians can discuss the evidence in real time. This can help identify where they agree and, just as importantly, where they don’t. That broader clinical perspective can be valuable before a consequential decision, such as complex surgery or a transfer of care.
The Right Physician Matters as Much as the Type of Review
Choosing between a record review, IME, peer-to-peer consultation, or multidisciplinary review is only half of the decision.
Who performs the review matters just as much.
Orthopedic medicine has become highly subspecialized. A complex shoulder condition may be better evaluated by a physician whose practice focuses on shoulder surgery. A revision spine procedure may warrant review by a surgeon who regularly manages complex spine cases.
Board certification and appropriate credentials remain important. But for a complex workers’ compensation claim, experience with the specific condition or procedure can add another level of clinical relevance. This is particularly important when the opinion may influence a major treatment decision.
From More Medical Opinions to Better Clinical Clarity
Expert medical review shouldn’t become another box to check in an already complicated workers’ compensation claim. A well-selected review should accomplish something. It should answer the question that is creating uncertainty and provide useful information about what happens next.
Sometimes that requires an independent physical examination. Other times, a subspecialist may be able to answer the question using the medical records and imaging already available. A conversation between physicians may resolve a treatment disagreement. Particularly complex claims may need several specialists at the table.
The objective is simple:
Choose the medical expertise and review process that best fit the decision that needs to be made.
When that happens at the right point in the claim, expert medical review can do more than generate another report. It can help reduce clinical uncertainty and keep the injured worker moving toward an appropriate resolution.
Get the Right Medical Expertise for the Question at Hand
BICMD helps carriers, TPAs, employers, adjusters, and case managers select the appropriate level of medical review for complex workers’ compensation claims. Through Expert Medical Opinions, Age of Injury analysis, physician-to-physician consultation, MD Roundtables, and access to orthopedic subspecialists, BICMD helps stakeholders get focused clinical answers without automatically defaulting to the same review process for every claim.
Contact BICMD to discuss the clinical question in your claim and determine which type of expert medical review can provide the clearest path forward.
