Independent Medical/Chiropractic Examinations

Most doctors of chiropractic don't like their patients to be forced to undergo IMEs. This is based on a number of fairly understandable considerations:

1. DCs do not like another DC or MD judging them and reviewing their records or their treatments.


2. DCs feel that, in many cases, their patients are not going to have a fair and comprehensive examination.


3. The majority of IMEs say there is nothing wrong with their patients and that no further chiropractic care is necessitated, when in fact the patients have objective as well as objectively substantiated subjective symptoms.


4. The opinion(s) of the IME are most often not objectively substantiated, yet give authority to the patients' insurance company to deny further reimbursement of treatment.


5. DCs feel that the only IMEs insurance companies use are those who are anti-patient, anti-chiropractic, pro-insurance and not neutral.


6. The IME's examination and resulting report and opinions lack credibility.


7. The opinions of IMEs are narrow, one-sided and prejudiced against DCs and their patients, and hold no scientific validity.

To varying degrees, all of these opinions hold validity.

So What Does One Do? The Best Defense Is the Best Offense

With that in mind, let's look at the following factors as they apply to Risk Management and IMEs:

1. Because we live in a litigious and hedonistic society, every doctor of chiropractic who is involved in caring for people injured on the job or during personal time is going to be reviewed by IMEs and have complaints filed against them by patients' attorneys and insurance companies.


2. Every doctor of chiropractic who is attempting to provide the best possible diagnostic as well as treatment services to injured people is going to experience their patients being forced into having IMEs.


3. Until more Boards of Chiropractic (Colorado is a good example), Medical Examiners and/or courts of law take stronger control of the business (and it's a big business) of IMEs, treating doctors of chiropractic and their patients are going to continue to experience abuse.


4. In legislatively restructuring the way the business of independent medical examinations are regulated, all IMEs and peer reviews should go through the Board of Chiropractic Examiners, and no member of a peer review committee or board of chiropractic examiners should be allowed to perform peer review or independent medical examinations for five years after they have completed their term.

This is an imperfect world, comprised of a minority of people who are looking for a free ride, to gain from others, are judgmental, critical and refuse to do unto others as they would have others do unto them. Greed, selfish ambition and hate prevail in the hearts of many people, and that lack of love for others is why these few spend their time making trouble for so many others.

The best you can do is be the best you can do. In the process, keep on sowing good seed into good ground. As you choose to do so, you are sowing seeds that will bear good harvests. Love those who accept your love, and call as much mercy and grace upon all humankind as you would call upon yourself. There are good things we can learn and utilize from adverse experiences when we choose to look for them. Let us never allow the negative few to overrule the positive many. Life is too short to harbor anger or resentment against those who have hurt us. We have so much good to offer so many and we can if we use the negative past as a stepping stone to a positive future.

Practice Excellence

The best defense against IMEs is practicing excellence. Doctors of chiropractic who seek excellence in the principles that we've been addressing in our column are going to make some positive things happen for themselves and their patients. Practicing excellence will:

1. reduce the incidence of their patients being forced into IMEs;


2. cause insurance companies, claims handlers, commercial review companies, defense attorneys and IMEs to become less inclined to short-change their patients;


3. let all insurance companies and IMEs in their area know that they're going to go after them legally if they fail to pursue excellence in the handling of their patient;


4. Put DCs in the position, if the situation arises, to expose any areas in the IME's and/or peer reviewer's report that are one-sided, prejudiced, dishonest, abusive or lacking scientific credibility.

When doctors of chiropractic practice excellence, not only are patients better served, but DCs can spend their time caring for people rather than being consumed with preventable hassles and paper work that always result from not practicing excellence.

What's Good for the Goose Is Good for the Gander

There isn't any better defense against prejudiced peer reviewers, insurance companies and the IMEs than records that clearly show that you did a comprehensive intake consultation; past medical history; present symptoms and complaints; full postural, orthopedic and neurological examinations; made x-rays where injuries and symptoms warranted; produced diagnoses consistent with the history and the patient's responses to examinations performed; gave and followed the treatment plan; made second-opinion referrals; produced daily chart (SOAP) notes that were at best typed or at worst handwritten; conducted regularly scheduled re-evaluations; made appropriate changes in the diagnosis and treatment plan; and submitted reports of the results of said re-evaluations to a patient's insurance company (and attorney, if he/she had one).

IMEs Should Be Held Accountable

The same holds true for the patient's visit with the IME. If the IME does not perform the same services (consultation, take a past medical history, inquire about present symptoms and complaints, perform a complete postural, orthopedic and neurological examination) at the highest possible level of professional integrity and scientific expertise, then your review report of the IME should state so, and the patient's attorney as well as the IME's respective board of examiners should be notified in the form of an official complaint.

Preparing Your Patient for an IME

Because we are held responsible to always do what's best for all of our patients, it makes sense that IMEs be held accountable to the same practice requirements that we are. If there are IMEs in your area who do not treat patients fairly, you need to consider offering your patient information regarding what should occur during their IME. Never attempt to criticize the IME, prejudice the patient or encourage them to lie or be defensive. Patients should be encouraged to be pleasant, cooperative and should be offered the use of the following forms and questions prior to their IME:

Confidential Summary of Independent Medical Examination Form

This can be accomplished by having preprinted forms that the patient uses to fill in and answer the following questions regarding:

• date of examination
• name of examining doctor
• address of doctor's office
• time patient entered the IME's office
• time history began
• time history was completed
• time examination began
• time examination was completed
• when you last menstruated?
• Who else was in attendance during your IME?
• Did any person record or write down what you told the IME
• Did the IME and/or assistant record your responses to examinations?
• How were you feeling prior to the IME?
• What did you feel like after the IME?
• Were your breasts, pelvis, or groin touched or examined?
• Did the IME make any suggestions or comments about your condition
• Did the IME make any comments about the doctor you're treating with?

Patients should also be given forms (which they can fill out) showing illustrations of orthopedic and neurological examinations that would typically be utilized, and offering them the opportunity to indicate which of the illustrated tests were performed. The patient is best seen the day of, or at the latest the day after the IME by their treating doctor. The treating doctor then reviews the information the patient recorded on the Confidential Summary Of IME forms, as well as the forms that illustrate what tests were performed.

Review Report of Your Patient's IME

The data the patient gives you from their IME, and their responses to the re-evaluation you conduct are recorded. When the patient or his/her attorney supplies you with a copy of the IME report, compare it to what the patient told you occurred during the IME, as well as the patient's responses to the re-evaluation you conducted after the IME.

Assessing the Credibility of IMEs

Any inconsistencies in the IME report should be noted, including:

1. if those inconsistencies are outright lies;


2. if the IME report states the tests were performed but actually weren't;


3. if any opinion is unsubstantiated by documented examinations;


4. if the examiner did not, in your opinion, perform an examination fully relative to the patient's history and or present complaints;


5. if the IME was a doctor of chiropractic and did not include customary postural, orthopedic and neurological tests taught in chiropractic colleges;


6. if the IME was a medical doctor and gave an opinion about chiropractic care, but did not include customary postural, orthopedic and neurological tests relative to the patient's condition; and


7. any other inconsistencies or problems identified in the IME report. IME's respective licensing board.

You're in a Business

No one enjoys adversarial relations without paying a heavy price. Certainly the area of IMEs needs regulation and greater control, but at present the best thing we can do is do the best we can for our patients. If you feel that you or your patients have been treated unfairly, pursue the legal options open to you, and then get on with your mission of serving people. Don't get hung up on IMEs, or anyone that's adversarial. Every IME, member of a peer-review committee or person who was on board of examiners that we've ever known has told us that their practice suffered and went down when they involved themselves in performing IMEs, doing peer reviews and/or sitting on boards of examiners. No one can avoid the deleterious consequences of involving themselves in the judgment of others. At times it may seem fun to be in a position of power or to look into and make decisions about the lives of others. But people who sit in judgment of others call major problems into their lives in multiple ways. Let us get on with the business of helping others, for there has never been a better time to be in chiropractic. Never have there been as many doors of opportunity to share the gospel of chiropractic. Those who take a positive attitude about everything will eventually find positives coming out of all things.

Jerry Lalla, DC
Diane Lalla, CA
2353 Rice Street
Roseville, Minnesota
glalla-greatphysician.com
www.greatphysician.com