Perhaps one reason why medical tourism has yet to penetrate the ‘Iron Curtain’ that surrounds the American workers’ compensation system is that unlike health care, workers’ compensation is very adversarial in nature and by design.
To illustrate, imagine a worker gets hurt on the job and goes to his boss to file a claim. Now, the boss has to have someone in his office file the necessary paperwork to the appropriate state agency and the employer’s insurance carrier to get the claim processed. If the employee loses more than seven days of work (the typical length of time is called a ‘waiting period’ in most states), the employee begins to collect benefits, and if the injury is serious, will hire an attorney to represent him in all future litigation and adjudication of his claim.
The employer too will get an attorney, either through his insurance company, or on his own. Finally, the insurance company will also have an attorney to represent their interests in the claim process, especially if the employer has a separate firm defending them. What then takes place in the course of the claim is a “three-ring circus”, with the injured worker in one ring, the employer in another, and the insurance company in the third and final ring. And you wonder why it is so screwed up?
Alongside all of these parties are companies that assist the employer or the insurance company to reduce their claims costs or to figure out the best way to minimize the losses to the insurance company’s bottom-line that a major workers’ compensation claim will likely cause the insurer.
One such company is Amaxx Risk Solutions, Inc., and the Principal, Michael Stack has written a short article recently on WorkersCompensation.com’s Workers Comp Blogwire, about how an employer or insurer can help their case by having the adjuster choose the right IME doctor. An IME, or Independent Medical Exam is usually ordered by the insurance company or the injured worker’s lawyer to determine if the injury is compensable, that is, able to be paid for by the insurance company.
The article, Your IME Doctor Selection Can Make or Break Your Case, advises employers and insurers on how to get the adjuster to choose the right doctor for the independent medical exam. Back in April, I wrote an article about how self-insured employers can choose the right adjuster, now Michael Stack’s article tells employers and insurers what to do when needing a good IME doctor.
According to Stack, adjusters choosing the wrong IME doctors are one of the common errors he notices in workers’ comp files. Choosing a practicing specialist is the best IME doctor, he says. For example, if there is a tough wrist injury surgery ordered and you need to see if the surgery is related to the comp case, then using a general orthopedist who no longer performs surgery or who is not board certified is not the best choice. A practicing physician who still performs many surgeries, especially wrist and hand surgery as a specialist, and is up-to-date on the latest techniques and practices is the better choice, Stack says.
This error is due to the fact, Stack writes, that the adjusters are not familiar with their territory. This maybe because they are in a different state, are new to claims, or have a habit of letting the IME marketer choose the doctor, especially when the marketer does not know anything about the case.
However, he adds, if your goal is to get a post-operative patient back to work and you are only interested in work restrictions, then many doctors would suffice. Treating doctors are hesitant to put their post-op patients back to work based on the history the claimant gives them at the appointment. Not educating the doctor about light duty programs is why an IME is needed. An IME is a valuable tool for the adjuster, so you need to choose the correct one early and stick with them, Stack goes on to say.
Using a nurse case manager when the employer or insurer is not familiar with the IME doctors in the area is another recommendation Stack makes. These nurse case managers have seen a lot of these doctors because that is the territory they work, and they can also attend the IME and follow up with them after the appointment to see that all of the employer’s questions are addressed.
Lastly, the wrong IME opinion is not worth the paper it’s printed on says Stack. If your doctor has zero credibility, when the litigation begins, you will be in trouble. He advises to take the time when you choose that first IME doctor, because if he is a general occupational medicine doctor, and he is up against a well-respected specialist, your defense will not be solid. A doctor who still treats and operates and is up-to-date with all techniques and trends will give you a real defense, Stack says.
Why is this important for the medical tourism industry to know?
It is important because before any facilitator can offer their services to self-insured employers, or employers who purchase workers’ comp insurance, or insurance companies wanting to save money on expensive surgeries, knowing what goes on in a workers’ comp claim will mean a better outcome for the patient, and more customers for the facilitator.
It will prove to the employer or the insurer that the facilitator is not just selling them a paid vacation for their injured employee or claimant, but a real alternative to high-cost medical care in a facility with the same or better quality than what is available locally.
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