What is an Independent Medical Examination (IME)?

Whenever any person puts his or her mental or physical condition at issue in any case which compensation is sought, insurance companies have the right to have a physician of its own choice to examine the client.  Normally, insurance companies accomplish this by obtaining what is known as an IME, which is a medical examination of the patient that is conducted by a doctor who is paid by the insurance company to conduct the examination.

Generally, the IME is scheduled by agreement of both parties; however, if the injured party does not cooperate, the insurance company may seek a court order requiring the patient to attend the IME.  The insurance company will send a letter to the injured party indicating the date, time, and specialty of the doctor who will perform the IME, along with any requests for medical records that the insurance company is entitled to ask the patient to bring with him or her to the IME.

The purpose of an IME is for the insurance company to verify, by having its own doctor examine the patient, that the services provided for the injured party were medically necessary; additionally, IMEs can be used for the purpose of determining whether or not medical benefits for the injured party will continue.  After the IME is conducted, the doctor puts together a report, called an “IME Report,” and submits the report to the insurance company to review.  The report generally contains the doctor’s findings during the examination, and whether or not in the doctor’s opinion, the medical services in question were medically necessary.

What Happens at an IME?

IME examinations are cursory at best.  Doctors performing IMEs make thousands of dollars conducting these examinations for insurance companies, yet most examinations last anywhere from 5 – 10 minutes, and are generally limited to the following:

·         Completion of a medical-history form by the patient

·         A review of available documents provided by the treating physician

·         A brief medical exam

·         Recording of doctor’s opinions and impressions of the patient.

The Law and IMEs

After an insurance company receives a claim from a medical provider whether orally or in writing, the insurance company has a right to “additional verification” before it determines whether it is going to pay or deny the claim.  Insurance companies must request verification not once, but TWICE, before it is able to deny a claim.  Therefore, if the requested verification is not complied with by the medical provider the first time, before the insurance company denies the claim, it must issue a second request for the verification.  If that second request is not complied with, then the insurance company may deny the claim.

According to New York insurance regulations, insurers are entitled to IMEs as “additional verification” following the receipt of a medical provider’s claim forms; this verification process works to rule out any potential fraudulent claims. All medical examinations requested by the insurer are held at a place and time reasonably convenient to the patient, and the patient will be reimbursed for any loss of earnings and reasonable transportation expenses incurred in complying with the request.

If after the IME, the insurance company denies the claim, this does NOT mean that the treating medical provider must stop treatment, or that there will be no payment for services.  If the patient’s symptoms remain, and it is the opinion of the treating physician that medical treatment is warranted, then medical treatment should be continued.  After an IME denial, medical treatment can still be rendered, and all bills can be litigated or arbitrated.  97.5% of IME denials DO NOT hold up in court or arbitration, and the insurance companies are required to pay the treating physicians.

Since the doctors are paid by insurance companies to conduct this “independent” medical examination, it is hard to believe that these examinations are in fact “independent” of what the insurance companies are claiming to be medically necessary.  At AMSAC, we ensure that every denial based on the results of an IME made by an insurance company is opposed, and we specialize in collection of these denials based on IME.  AMSAC has successfully collected on thousands of IME denials.

Please note that is very important to save all IME denials received in the mail from insurance companies.  At AMSAC, we specialize in collection for medical treatment rendered after an IME denial, and you can be sure that all documentation received in the mail is automatically attached to the patient’s billing account within 72 hours.

What Happens if the Injured Patient does not Attend the Scheduled IME?

Technically, when a patient fails to comply with an insurer’s reasonable request for an IME, that person has failed to meet a condition precedent for No-Fault coverage and therefore, any pending claim submitted for services rendered may be denied due to the policy breach.[1]

To be clear, an insurer CANNOT issue a denial after one IME no-show.  Insurers also may not issue a denial based on an first-time IME no-show, and then tell the insured that it will take back the denial after the patient shows up to the second IME.[2]  The insurer must wait until  the patient fails to attend two IMEs before it denies the claim.  Remember, a demand for an IME is a verification request, which means there must be 2 requests before an insurer is allowed to deny a claim.[3]

Steven Fogel Psychological, P.C. v. Progressive Cas. Ins. Co.[4] is the lead case on IME no-shows in New York as of 2006.  Before Steven Fogel, the rule was that the earliest date that  insurance companies were permitted to cut off benefits based on IME no-show, is the date of the SECOND no-show. In other words, benefits could not be cut off retroactively.[5] In 2006, the Court concluded that an insurer may deny a claim retroactively to the date of loss for a claimant’s failure to attend IMEs when, and as often as, the insurer may reasonably require.[6]  But even Steven Fogel does not give insurance companies a rock-solid basis for automatically denying claims.

The Insurance Department is clear in an opinion letter dated 2/14/05 in stating that if a patient fails to show up for an IME twice, but offers a reasonable excuse for not attending the examinations, and is attempting to establish (in cooperation with the No-Fault insurer) a reasonably convenient time to attend, then insurance companies must wait to deny the claim.

Excuses that have been found to be reasonable are the following (this list is not exhaustive):

  • IME was scheduled at an inconvenient time or an inconvenient place
  • Work or school schedules conflict with the scheduled IME
  • Family emergencies
  • Bad weather
  • Etc.

In other words, Courts tend to be liberal in excusing the IME no-show if the patient shows that he is attempting to cooperate with the insurance company in rescheduling another appointment, and is acting in good faith.

How do I know that the IME is being Fairly Conducted?

A doctor who is paid by an insurance company to conduct a medical examination of a party who is adverse to the insurance company, to determine whether or not the insurance company should pay or deny a claim made by the medical provider, seems awfully questionable.  Many times questions are raised as to how the medical provider knows that the IME is being conducted fairly.  How do we know if the insurance company doctor is truly reporting what the patient is saying? How do we know that the doctor is doing a true thorough examination?

Doctors are required to rise to their standard of professional ethics; however, to be certain, patients ARE legally allowed to record the IME themselves.  Tape recorders, use of an extra witness during the exam, and even video cameras have been used.

Medical providers rest assure, 97.5% of IME denials are NOT upheld in litigation or arbitration, and here at AMSAC, we pride ourselves on exceeding that standard.

[1] Rogak, Lawrence N. Rogak’s New York No-Fault Law & Practice. Second. iUniverse, 2009. 277. Print.
[2] Id. at 272.
[3] Id.
[4] Steven Fogel Psychological, P.C. v. Progressive Cas. Ins. Co., 2006 NY Slip Op 09604
[5] Id.
[6] Rogak, supra, note 1 at 273.