How bad does an IME have to be before you file a medical board complaint?

[rev ronin]

For those of you not in occupational medicine, you probably still have some insight here. How bad does an independent medical exam have to be before you complain about unprofessional conduct and/or inability to practice medicine with skill and safety to the relevant licensing board?

Example 1: Patient contends bunion from work boots as an occupational disease.

IME: That's about ten degrees, not significant, and not work related anyways.

Reality: I just measured it in clinic. It's 30 degrees (borderline moderate), not 10. I sent in photos with and without a goniometer in frame.

 

So, these retirement-age MDs get paid thousands of dollars to render opinions notionally within their medical specialties... and many of them are unhelpful, but some are outright perniciously wrong. Some examiners are quite busy, and they tend to lack egregious errors, but the 75+ year old MD who just shows up once and provides a lamentably bad report that is prejudicial to my patient is a not uncommon problem. What would your criteria be for making a board complaint rather than just rebutting the nonsense report?

[Mayamom]

Even if you make a complaint would they do anything about it?

[SedRate]

I guess my first thoughts are how one would determine if the bunions are from work boots specifically and not any other footwear the pt might've worn throughout their lives. A family history of bunions or arthritis could predispose pt to them as well, so I'm assuming the pt reported no history. Also, why is the pt seeking disability rating? I'm not sure I've heard of pts receiving disability rating for bunions before...

I wouldn't report it personally. If I was convinced it was from work boots that the pt had no choice in wearing and were properly fitted (and not the pt wearing too small a size), I would rebuttal and not send anymore pts to that IME provider. As for the measurements being off and whether that warrants reporting, I can tell you there are a whole lot of providers out there who can't measure or do a proper exam...

[Cideous]

2 hours ago, Mayamom said:

Even if you make a complaint would they do anything about it?

As someone who investigates this stuff the is....no.  Anyone could file a complaint, but it would most likely be closed without incident ASAP.

Edited May 13, 2023 by Cideous

[Reality Check 2]

I have seen over 1000 IMEs over the years, I would calculate.

Never considered them truly independent and unbiased. Can only count a handful I would consider well done, accurate or even with effort.

Patients deserve better and a retired whatever doctor  should not be making money by doing a half arse job. 

The system needs an overhaul and perhaps open IMEs to PAs with specialty experience in the needed field.

IMEs come with a heinous manual and vary state by state. 

Found this from 2017 as “guidelines”.  Perhaps review the IME you have to see if it meets these…. 

Make a complaint off of that.

Wonder if patients can demand they be filmed?…

I do not agree that bunions are necessarily related to work shoes, but that is another discussion.

IMEs are horribly substandard and not fair to the injured employer.

Well written letters contradicting them and demanding further consideration are the only thing I can think of to start with. 
 

I forgot to add the link, chasing it back down.

https://www.impairment.com/wp-content/uploads/2019/02/IME_Best_Practices.pdf

Edited May 13, 2023 by Reality Check 2

[ventana]

The more I see of our screwed up system the more I want my own little practice where I can do it correctly every time.   We are a whisper away from an implosion.  Honestly the medical boards “policing themselves” is a total failure except for most horrible cases.   
 

if I got back a substandard IME I would talk to the examiner gaining all their info.  Ie when last time they were in practice,  year of graduation.  Boarded speciality and so on.  
Then I would oh so professionally tear apart their evaluation with my own.   Then be prepared for the subpoena cause you are getting called to court if it goes that far.  

[SedRate]

1 hour ago, ventana said:

The more I see of our screwed up system the more I want my own little practice where I can do it correctly every time.   We are a whisper away from an implosion.  Honestly the medical boards “policing themselves” is a total failure except for most horrible cases.   

Yep

[Cideous]

1 hour ago, ventana said:

The more I see of our screwed up system the more I want my own little practice where I can do it correctly every time.   We are a whisper away from an implosion.  Honestly the medical boards “policing themselves” is a total failure except for most horrible cases.   
 

if I got back a substandard IME I would talk to the examiner gaining all their info.  Ie when last time they were in practice,  year of graduation.  Boarded speciality and so on.  
Then I would oh so professionally tear apart their evaluation with my own.   Then be prepared for the subpoena cause you are getting called to court if it goes that far.  

The backlog of work for us is....stunning to behold.  It's almost laughable, hence only the most heinous stuff makes a blip on our radar.

[rev ronin]

On 5/13/2023 at 7:04 AM, SedRate said:

I guess my first thoughts are how one would determine if the bunions are from work boots specifically and not any other footwear

Totally not the point.

The examiner lied, by a factor of three. He's entitled to his opinion, and I to mine, and we get references to back our viewpoints up, and the lawyers slug it out in front of an administrative law judge. That's all fine; that's how the system works.

But the system is supposed to rely on such examiners to actually represent reality accurately. If they're not even doing that, what's the point of having a disagreement about causality when they won't even accurately report an easily measurable number?

[rev ronin]

On 5/13/2023 at 1:13 PM, Reality Check 2 said:

I have seen over 1000 IMEs over the years, I would calculate.

Never considered them truly independent and unbiased. Can only count a handful I would consider well done, accurate or even with effort.

Wow, that's terrible. I would say in my IME experience 20% are helpful, 30% are irrelevant, and 50% are wrong or inappropriately biased against the patient.  That isn't me grading based on how they agree with me, but rather how thorough and professional they are. It's rare that I can't find something to argue about in an IME, but there are plenty that are relatively well done, don't internally contradict themselves, remember what conditions are being contended, etc.

With respect to filming IMEs, Washington, hidden among its other medical bills that made national headlines, passed HB1068 such that recording is now permitted in IMEs:

https://lawfilesext.leg.wa.gov/biennium/2023-24/Pdf/Bills/Session Laws/House/1068-S.SL.pdf?q=20230514141947

 

[rev ronin]

On 5/13/2023 at 2:08 PM, ventana said:

if I got back a substandard IME I would talk to the examiner gaining all their info.  Ie when last time they were in practice,  year of graduation.  Boarded speciality and so on.

Board certification is listed in the IMEs. I hadn't considered requesting the other items. Any luck getting them so far, or has this mostly just been theoretical?

[SedRate]

8 minutes ago, rev ronin said:

The examiner lied, by a factor of three

 

On 5/13/2023 at 12:21 AM, rev ronin said:

IME: That's about ten degrees, not significant, and not work related anyways.

 

On 5/13/2023 at 12:21 AM, rev ronin said:

I just measured it in clinic. It's 30 degrees (borderline moderate), not 10

On 5/13/2023 at 8:04 AM, SedRate said:

As for the measurements being off and whether that warrants reporting, I can tell you there are a whole lot of providers out there who can't measure or do a proper exam...

Exams should be ubiquitous and objective. Sadly, in reality, they are not and there is a ton of subjectivity or just straight up poor exam skills. I've had hospitalists consult me to perform a MSK exam, stating they are not experts at the MSK exam. Sad. 

Good for you for doing a quality exam. 

[ventana]

On 5/14/2023 at 5:25 PM, rev ronin said:

Board certification is listed in the IMEs. I hadn't considered requesting the other items. Any luck getting them so far, or has this mostly just been theoretical?

 

I do this for insurance doc's for prior auth's.... amazing what you learn and how it puts them on the defensive.

[Febrifuge]

I had one for a long-COVID patient and the examiner said he had treated over 1000 cases of acute COVID, with none of them ever having symptoms lasting longer than 4 weeks. Later in the same report he brushed off some findings from a Pulmonary visit as being something that can happen after COVID.

So I provided a letter to the patient's lawyer at their request, pointing out the contradiction and wondering why, if the CDC and the NHS estimate 10-20% of COVID cases have symptoms persisting past 6 weeks, this guy somehow saw 1000 of them and none had persistent symptoms. 

Through the grapevine I heard the attorney was huffing about how I should leave the argumentation to them. Ya can't win. 

[rev ronin]

18 hours ago, Febrifuge said:

Through the grapevine I heard the attorney was huffing about how I should leave the argumentation to them. Ya can't win. 

Wow, your attorney's an idiot.  I use a volleyball team analogy: I'm the setter--establishing the medical arguments, standard of care, etc.--and the attorney's the spiker.  It's my job to set them up well... within the confines of when doing so serves both truth and my patient's best interest.

I get referrals from about 6-8 law offices, and they just love it when I take 2-3 hours to pick apart a terrible IME like that.  I've had a couple attorneys say I make their jobs easier.  Of course you have to keep roles clear and remember that attorneys serve the patient's financial best interest first, because they get a slice of the money, and I need to recommend the non-most-money option sometimes when it's really what's best for the patient.

[ventana]

rev - how do you get the IME contest patients??

[rev ronin]

48 minutes ago, ventana said:

rev - how do you get the IME contest patients??

I just specialize in weird, old, complex claims. I take them when no one else will.