What to know about your medical evaluation for a workers’ compensation claim
Some people hate going to the doctor. Maybe they just feel uncomfortable, or maybe they are worried that the doctor will say something they don’t want to hear.
But there are some circumstances when it becomes a necessity, and when you can’t put it off any longer. One of those is if you’re filing a workers’ compensation claim. Even though each state has its own laws around workers’ compensation claims and benefits, one thing is universal:
If you’re filing a claim for a work-related injury or illness, you’ll need a medical evaluation and diagnosis by a doctor approved by the insurance company that provides your employer’s workers’ compensation benefits.
An Independent Medical Examination (IME) must be performed by a doctor approved by the insurance company, but you may also be able to seek treatment by your own doctor or provider of choice depending on the laws in your state.
How to prepare for your workers’ compensation medical evaluation (5 tips)
- Request records from the insurance company. The insurer will probably send copies of your medical records to the doctor ahead of time, and you can request a copy of those records so that you can verify their accuracy.
- Prepare notes on how the accident happened. Or, at a minimum, make sure you recall the events clearly and can tell the doctor in your own words how you were injured. Your description of the accident as you tell it to the doctor must match what was reported to the insurance company — they will be looking for inconsistencies or changes.
- Don’t expect confidentiality. You’ve probably heard a lot about HIPAA (the Health Insurance Portability and Accountability Act), which is a fancy way to say that your medical interactions and records are private and a doctor or medical provider may not share them with anyone without your permission. Workers’ compensation medical evaluations aren’t subject to HIPAA.
It’s the doctor’s job to report the details to the insurance company, which includes details of the physical examination and anything you tell them during the course of the evaluation. You might be observed from the moment you walk into the facility until you leave. If it looks like a struggle for you to get out of a chair in the waiting room or remove your shoes — or if you look as agile as a gazelle — it could be noted in your chart.
- Expect to discuss pre-existing conditions. You might be asked how the effects of your work-related injury are different from your “regular” symptoms or experiences related to other aspects of your medical history.
- Bring a friend or family member. It’s a good idea to have someone with you during the exam to take notes and be a witness to the exam.
What to do during your IME
Be honest about your symptoms and physical limitations.
Doctors have ways of knowing if people are accurately reporting how they feel. Don’t try to exaggerate your condition because the doctor might note that in the chart, and you will lose credibility.
At the same time, be realistic about how you do feel. Some physical symptoms might seem embarrassing, but it’s important to give the doctor a clear picture of what you’re experiencing. Otherwise, you only shortchange yourself.
Be clear about your pre-existing conditions.
It’s equally important to share if the injury impacted a body part that was already compromised because of an earlier injury or condition as it is to let the doctor know what new symptoms, pain, or limitations you’re feeling.
Ask questions about what to expect for treatment.
Most IME doctors are generalists. They aren’t necessarily orthopedists or other specialists, so they don’t always know the specifics of what you’ll need or the most up-to-date methods for treatment. Still, they can give you an idea of what type of treatment would be appropriate for your injury.
Take photos of your injury.
If your injury is visible, such as swelling or redness, take photos during your time in the office for the IME. Take the photo strategically so it’s clear that it was taken in that particular medical office. This way, if the doctor says they didn’t see a visible manifestation of injury, you can prove otherwise.
This might seem like kindergarten advice, but even adults need reminders sometimes. The doctor might not be super-friendly. They’re not there to give advice, be your friend, or support you. Their job is to serve as an expert who provides a report to the insurance company. The insurance company pays them for their objective opinion about whether to approve your claim and for how much.
The doctor has no interest in making your injury seem any worse than it is; in fact, they might write a report in a way that would suggest less treatment than your own doctor thinks is necessary. But regardless of their demeanor, keep it polite and professional. Being hostile or accusatory to the doctor definitely won’t help your claim.
What NOT to say during your IME
- Don’t ask for a diagnosis. The doctor is expected to write an evaluation based on their observations of your condition and the extent of your injury. They do not always make a diagnosis.
- Don’t exaggerate your symptoms. If the insurance company learns that you weren’t truthful, they will be more likely to deny your claim. Insurance companies do regularly hire private detectives and use other kinds of surveillance to see how you act when you don’t think you’re being watched.
- Don’t offer more information than you need to. In other words, answer questions honestly but don’t give more than what’s asked. The more you talk, the more you risk saying something that seems inconsistent or that’s against your interests. If you’re chatty by nature, resist the urge to make small talk or overshare.
- Be careful when completing paperwork or forms. The IME doctor should already have documents explaining your injury and your medical history. If you’re asked to rewrite the details of how the injury happened or what your symptoms are, don’t. The insurance company already has this information and they might be asking you to do it again to see if your story changes.
- Don’t use definitive words like “always”, “never”, or “can’t”. Instead, use words like “usually” or “most of the time”. This avoids the suggestion that your symptoms or physical condition are always the same, which would make it seem less credible.
- Don’t say something is painful if it isn’t. We’ve all had a doctor say, “tell me when this hurts.” But sometimes a doctor will maneuver your body in a way that they don’t expect to hurt in order to get a better impression of the true and accurate amount of pain. If you say something hurts when it doesn’t, the doctor might think you’re not being truthful about other aspects of your condition.
4 tips for following up after an IME
A doctor who performs IMEs is paid to do so by the insurance company. The doctor’s motivation is to keep the insurance company happy, which might mean writing a report to minimize your injury so that the insurance company can justify paying less for your treatment.
Here are a few things you can do if you suspect that the IME report might not accurately reflect your condition:
- Request a copy of the report. You can refuse to talk with the adjuster until you’ve received a full copy of the report. You don’t have to rely on the adjuster to share with you portions of what it says.
- If the evaluation was unfair, say so. If the doctor didn’t review your medical history, didn’t ask about your symptoms, or was too rushed to give a thorough examination, you have a right to complain.
- Highlight inaccuracies. If the doctor’s report is inaccurate or incomplete, you can show that it’s unreliable. You can support this by providing your own medical records if they contain information that isn’t included in the IME report.
- Have your doctor submit a response. The insurance adjuster will largely rely on the IME to gauge how much your claim should be worth. But if the IME report is very negative, incomplete, or understates your injuries, you can visit your own doctor for a second opinion. You can ask your doctor (or a specialist) to send the insurance company a response. Sometimes, there can be an extra charge by a doctor to write a response, so ask ahead of time what the charge will be so you’re not caught by surprise.
How your workers’ compensation lawyer can help
Your lawyer will advocate for you in determining whether there are any issues or inaccuracies in the IME. For example, your lawyer might ask the insurance company for:
- The number of IME referrals the doctor has had over the past 5 years
- How much the doctor is paid for each IME
- How many IMEs the doctor performs for plaintiffs’ attorneys, relative to the number of evaluations performed for insurance companies
The insurance company likely won’t provide this information, and it isn’t required to. But a phone call or letter from your attorney asking for it will put the insurance company on the defensive and prepare them that you’re not going to accept your settlement without some negotiation.
It’s helpful to call a lawyer before your IME, if possible. Most lawyers are trained negotiators and experienced with handling all kinds of workers’ compensation cases. They know the IME doctors’ and insurance companies’ tricks, and they can see through what might be an inaccurate report in order to get the amount you need for your benefits.
You deserve to be compensated for your work-related injury or illness, and you shouldn’t be shortchanged by an insurance company that doesn’t want to pay the full amount. The Enjuris Law Firm Directory is your guide to finding a workers’ compensation lawyer near you who’s experienced, compassionate, and ready to take your case.