Medical Peer Review vs. Independent Medical Examination – an Overview

Medical Peer Review vs. Independent Medical Examination – An Overview Medical peer review and IME are distinct processes. These are important from the viewpoint of disability claims processing and eligibility determination.

In any disability claim, the evaluation of the claimant’s medical diagnosis and how it prevents him or her from engaging in the usual and customary duties of his/her job is very significant. Since medical records are an important consideration, the service of medical review companies becomes very important to attorneys handling disability cases.

Typically, the insurer will have the applicant’s medical records reviewed by a physician specialized in the medical field pertaining to the applicant’s medical condition. This medical peer review will provide the insurer with a clinical opinion regarding the nature and extent of the applicant’s injury and how it affects him/her to carry out his job-related duties.

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There is some confusion among many people regarding a peer review and an independent medical examination (IME). Here is a look at how these differ from each other.

The peer review involves an evaluation of the available medical information in the medical records and related documents and provides a professional opinion regarding the claimant’s functional disability, and how it limits or restrains the claimant from doing his work. The peer review physician scrutinizes the medical records from all the providers, and apprises data collected from telephone interviews with the claimant as well as the providers. These interviews help in understanding more about the impairment and the limitations and restrictions it brings about, return to work planning and so on. Moreover, such direct conversation also enables the peer review physician to clarify any incongruity in the available data.

An independent medical examination involves a face-to-face clinical evaluation of the disability applicant. There would be a comprehensive interview, objective testing and preparation of a complete case history. The providers may be contacted to obtain any medical information necessary and all relevant medical records would be reviewed in detail. Data collected would include present illness, medical history, family and social history, work history, and so on. Functional abilities would be evaluated to ensure a more reliable inference. Usually, the IME is performed by a physician who was not previously involved in the care of the patient.

Peer review as well as IME provide expert clinical opinions regarding the applicant’s disability, restrictions and limitations, and the aptness of treatment provided. This information is vital to proceed to the next stage in the claim management process. So, what are the major differences between these two forms of medical evaluation?

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While an IME is an in-person medical evaluation, the peer review doesn’t involve such an examination.

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A peer review involves medical chart review whereas an IME may or may not involve such a review.

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The medical opinion in an IME is drawn from direct examination and objective testing of the patient while in a peer review, the clinical inferences are made by reviewing the information in the medical records, and the data provided by other healthcare providers and collateral information.

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An IME provides a more reliable or concrete evaluation.

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An IME may be more expensive and lengthier than the peer review.

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How does a payer decide which of these reviews is to be conducted? There are certain factors to consider in this regard.

An IME may be in place if: •

There is an evident difference of opinion between peer reviewers and/or treating physicians

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Clarity is needed regarding the medical diagnosis and suitable treatment

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The treating physician is reluctant to make available the required clinical data, progress notesor other documentation

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The incentive to return to work is an important concern

A peer review could be the better option if: •

An independent medical opinion is required regarding the information in the medical records submitted to the insurance company, so that an appropriate claim decision can be made

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There is some incongruity or ambiguity in the medical data provided by a treating physician

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Job-related concerns such as change in job duties, conflict with supervisors/coworkers, poor performance reviews and so on are involved

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Clarity is needed as regards the claimant’s work capacity, treatment planning, return to work planning etc.

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Treating physicians submit the same information continually with no change in the patient’s condition, treatment plan, or return to work status

Both medical peer review and independent medical examination are important processes in claim eligibility determination. These are performed with the purposes of preventing overutilization and containing healthcare costs, or to certify that an employee can/cannot carry out his/her work-associated duties. It is important to understand that these are distinct processes and when choosing one over the other you need to consider factors such as diagnosis, specialty, cost and time involved, and so on.

www.mosmedicalrecordreview.com

918-221-7791