Print Friendly, PDF & Email

Are IMEs Still Viable Given New UR Provisions?

By Christopher S. Crawford

Recently, a Petitioner’s attorney took the position with me that IMEs can no longer address the reasonableness of medical treatment given new Utilization Review provisions. Clients have also asked me about this position.

The reforms to the Workers’ Compensation Act have strengthened the Utilization Review provisions of the Act. When UR is requested, the provider recommending treatment must submit all notes supporting the rationale for continued treatment to the physician conducting the utilization review. The Act provides that the UR physician may address whether the requested treatment is excessive or unnecessary. The reviewer must also identify what standards of care are being relied upon in making the recommendation for medical treatment. The UR physician may address the reasonableness and necessity of proposed medical treatment. The Act also suggests that the physician can address causation. In the face of non-certification, the employee, through its provider, must show that the deviation from the standard of care and proposed treatment is necessary to relieve the employee of the ill effects of the injury. The deposition of the physician conducting the utilization review may be required in order to make the UR admissible. The Commission is required to consider the results of the utilization review in addressing the reasonableness and necessity of medical bills or treatment.

Nothing in these new provisions limits the parameters of an independent medical exam. Indeed, §12 examiners are still allowed to address causation and the reasonableness of medical treatment even with the reforms of the Act. The ability of a §12 examiner is more expansive than that of a physician authoring a UR. A §12 examiner can address work restrictions and the nature and extent of a person’s disability. A physician conducting a UR does not conduct a physical exam. A UR physician is not in a position to address a person’s ongoing restrictions or the nature and extent of disability.

The UR provisions under the Act have been strengthened. This is not going to diminish the usefulness of a §12 independent medical examination. Those will still be necessary going forward.

Originally published in the Spring 2012 edition of Quinn Quarterly.