Independent Medical Review Related Fraud Is a Major Concern

Independent Medical Review Related Fraud Is a Major Concern

Medical record review and medical claims review are vital in a workers’ comp or personal injury claim. Now IME related fraud has become a major concern.

MOS Medical www.mosmedicalrecordreview.com Record Reviews 8596 E. 101st Street, Suite H Tulsa, OK 74133

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The value of medical record review in workers’ compensation and personal injury cases is immense because it is this review process that determines whether the injury is compensable. An IME (independent medical examination) is also an important process – it is an objective, third party medical exam that may be requested by insurance companies, HR managers, lawyers, employers and benefit providers. An IME is performed when a person has been injured and third party evaluation is required to determine the extent of the injury. The IME report is used to grant or deny benefits, coverage or settlements to the injured person; it can also suggest steps for safe return-to-work procedures for employers to follow.

The independent medical examination can be performed only by a healthcare provider who has completed IME training and is an authorized IME provider. He/she cannot have an already existing patient-doctor relationship with the examinee. The IME is organized and managed by an independent medical evaluation company that is called for the purpose by the client. The IME company will arrange for objective, highly-qualified physicians who are within the claimant’s geographical location. While the IME is a very useful process, it is being abused in the U.S. healthcare system. Many insurers are alleged to rely on unethical defense doctors in an effort to cut off the much needed benefits due to workers’ compensation claimants and car crash injury victims.

On top of this is the concern of doctors themselves committing fraud. Spyros Panos, a former orthopedic surgeon is facing new federal charges for committing healthcare fraud begun while serving a prison sentence for another multi-million dollar healthcare fraud scheme, the DOJ (Department of Justice) said. Thousands of patients have received notices from insurance companies that Panos had pretended to be another doctor and reviewed their medical records in coverage disputes. It is estimated that around 2,500 people nationwide have been affected by this fraud. It is not clear whether Panos’ reviews have resulted in claims being denied. However, there is great concern regarding the oversight in the independent medical review industry considering how the fraud scheme went undetected for years. It is reported that Panos collected $876,000 since 2013 working on medical and workers’ compensation claims. He is said to have used a fake Gmail account, a shell company registered in a family member’s name to a Brooklyn, New York address, and another physician’s credentials to perpetrate fraud. Some of the IME companies involved assured authorities that they have taken steps to prevent unqualified people from becoming medical claim reviewers.

How can this kind of fraud or abuse be prevented? A michiganautolaw.com article makes 2 useful recommendations.

www.mosmedicalrecordreview.com

918-221-7791

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Doctors who conduct IMEs must be devoting most of their professional time to caring for, treating and healing the sick and injured people rather than doing litigation-related IMEs.

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Videotaping of IMEs should be mandatory or easily obtained at the request of the plaintiff attorney representing an injured victim who is being forced to submit to an IME. Videotaping is the best way of documenting everything that occurs and also what is said during an IME. It is the most effective way of holding IME doctors accountable to tell the truth.

A workers’ compensation or personal injury lawyer can provide the best advice to plaintiffs preparing for an IME exam. An experienced lawyer will review the medical record of the claimant with the support of a medical chart review company and determine the legal validity of the case. Plaintiffs would also need legal support to appeal in case a claim is denied.

www.mosmedicalrecordreview.com

918-221-7791