Treating: Doctors Can Fight & Overturn Improper IME and Peer Reviews


:dropcap_open:T:dropcap_close:he IME, or independent medical examination, and peer review processes are necessary and integral steps in maintaining a system of checks and balances in health care billing in order to prevent unnecessary care. Over the last two decades, the system has evolved to where too many doctors who are hired by the carriers through an IME company (middle man) or directly by the carriers are not performing examinations that are remotely close to independent. Going back 20-30 years, you could historically find inaccuracies in how the insurance companies hired doctors that reported on the conditions of the patients. 

improperimeandpeerreviewsIn addition, rarely were retrospective audits or retrospective opinions from contemporary IMEs performed or rendered. Today, this has become vogue and a huge revenue source for private, public and governmental carriers alike. There is hardly a doctor in the nation that hasn’t been affected by overwhelming negative IMEs that include inaccuracies, partial truths and a blatant disregard and/or misrepresentation of facts.  

Over the years, too many IME companies have handed doctors completed reports, mandated diagnoses, misquoted research and given strict orders regarding the scope of care permitted, all prior to the examination. In almost every instance I have encountered, the carrier or IME company has offered to send the doctor more cases if he/she works with them to reach a desired conclusion, whatever that may be.

Treating doctors currently have 2 choices. They can either ignore the opinions rendered which would tarnish or possibly damage their reputations as treating doctors or fight back with rebuttals. Unfortunately, most doctors choose to do nothing, leaving the final word of their clinical decision making and abilities up to the IME or peer review doctors. For the most part, based upon review of 100s of rebuttals, the doctors who do fight back with rebuttals are fraught with emotional statements and/or attempts to clarify the records.
Although this is a good first step, it comes down to a treating doctor’s word vs. an IME or peer review doctor’s opinion, and in the end the treating doctor rarely wins the argument. If you attempt to scrutinize the reasons why, it comes down to the fact that the IME and peer review processes are time-honored systems for which decades and countless resources have been spent defining templated language and research has often been supplied to the “insurance-hired” doctors. It’s an area where treating doctors do not have access to the same type of technology or research teams that the carriers and the IME companies can afford…and…there is nothing wrong with that. 

They just play the game at a higher level than you in order to keep their money…and…it is always about the money. The problem arises when the IME and peer review doctors step over the line of integrity and report partial truths and/or half truths, making glaring omissions, or simply are dishonest in reporting their findings. This is what needs to be focused on in “weeding out the bad ones” and setting the record straight.

Treating doctors are not powerless, but need to understand how to get past the rhetoric of a well-constructed IME or peer review report in order to bring out the inaccuracies, partial truths and blatant disregard of facts when those circumstances arise. In the November, 2011 and February, 2012 issues of this journal, I chronicled actions that can be taken by the treating doctors and state organizations. In March and April of 2012, I outlined the perils facing the IME and peer review doctors. You must first understand every aspect of the process in order to prevent having negative IMEs and peer reviews and prevail in overturning improper reports.
In order to craft a proper rebuttal, it is necessary that you understand the licensure standards of the doctor-patient relationship between the insurance-hired doctor and the patient. You also must understand the regulatory requirements in that examination and the IME or peer review doctor’s requirements to report the results. This is a state by state issue, as each state has independent rules on the required conduct of insurance-hired doctors.  You then must learn how to recognize when a partial truth or “untruth” is being documented by the examining doctor. It is that scenario which mandates that you protect both your reputation and your patient’s interests by rendering evidence of how licensure and regulatory standards were not adhered to. 
The language typically written by IME doctors is, “The above captioned claimant is examined in accordance with the restrictive rules concerning an independent medical evaluation. Prior to the evaluation, it was explained to the examinee that this appointment was for the purpose of evaluation only and not for care, treatment or consultation, and, therefore, no doctor-patient relationship would result.”  In many states, this statement alone is not consistent with court rulings and regulations and can be considered a licensure violation due to a misrepresentation of the facts. Rendering false reports, or misrepresenting material facts is also considered a licensure violation in many states. 

Massachusetts regulations state:
4.06: grounds for disciplinary action

The board may, by majority vote after a hearing conducted in accordance with M.G.L. C. 30a and 801 CMR 1.00 et seq., take disciplinary action against any registered chiropractor who holds a certificate of registration issued pursuant to M.G.L. c. 112, §§ 89 through 97 and 233 CMR 2.00. Grounds for such disciplinary action shall include, but shall not be limited to:

(11) engaging in, authorizing, or aiding or abetting, fraud, misrepresentation or deceit in connection with his or her practice of chiropractic, as defined in 233 CMR 4.10;

(12) making any false statement or misrepresentation of material fact in connection with any application or claim for payment of any health care benefit, as defined in 233 CMR 4.11;

Delaware’s regulation’s state: 
Title 24. Professions and occupations

Chapter 17. Medical practice act
Subchapter iv. Disciplinary regulation; proceedings of the board

§ 1731. Unprofessional conduct and inability to practice medicine
(a) A person to whom a certificate to practice medicine in this state has been issued may be disciplined by the board for unprofessional conduct, as defined in subsection (b) of this section, by means of levying a fine, or by the restriction, suspension, or revocation, either permanent or temporary, of that person’s certificate to practice medicine, or by other appropriate action, which may include a requirement that a person who is disciplined must complete specified continuing education courses. The board shall permanently revoke the certificate to practice medicine in this state of a person who is convicted of a felony sexual offense.

(b) “unprofessional conduct” includes but is not limited to any of the following acts or omissions:

(1) the use of any false, fraudulent, or forged statement or document or the use of any fraudulent, deceitful, dishonest, or unethical practice in connection with a certification, registration, or licensing requirement of this chapter, or in connection with the practice of medicine or other profession or occupation regulated under this chapter…

Every state has its own rules that must be adhered to. However, some states have separate rules for IME and peer review doctors. 

This is one of many avenues that can be taken to overturn improper IME and peer review reports, but remember, the IME and peer review doctors are entitled to their opinions and you do not have to like them or agree with them.  For those honest insurance-hired doctors, the solution is for you to simply write a better, more thoroughly documented accounting of your patient’s problems initially, and then rebut the IME doctor’s opinion with your own documentation or request that your patient get an independent opinion from a doctor of his/her own choosing.

For those insurance-hired doctors who have crossed the line of integrity, the only solution is to use the rules and regulations, through documented proof, of how they violated state licensure standards and the best proof is the insurance company-hired doctor’s own report. Don’t let inaccuracies about your clinical opinions and abilities be the last word.  

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