Independent Medical Examinations
As a doctor, you might already be familiar with independent medical examinations (IMEs). You might have even conducted an IME yourself, whether for the purposes of Florida’s PIP law, a workers’ compensation claim, or some other insurance-related matter. If you are unfamiliar with IMEs and their purpose, it’s important to know what they are and why insurance companies like them. IMEs are not your friend; they are another arrow in the insurance company’s quiver they use to puncture your claim for reimbursement when you treat a patient injured in an auto accident and seeking PIP benefits.
Below we discuss what IMEs are, when they can be required, and how they are used by insurance companies. If your claim for reimbursement of PIP benefits is being challenged, delayed, denied or underpaid by the insurance company, whether through the IME process or by other means, call Shuster & Saben for help. Our attorneys are leaders in the field when it comes to helping doctors collect from insurance companies for the treatment they provide to patients after a Florida car crash. We’ve helped countless medical providers over the years and are eager to help you too.
What Is an IME?
An IME is a physical or mental examination of the patient and/or the patient’s medical records conducted by a doctor hired by the insurance company. The IME is not a “second opinion”; the patient doesn’t listen to the doctor providing the IME and decide whether to switch providers. The doctor performing the IME does not do so for the purpose of treating the patient and doesn’t provide any treatment whatsoever or prescribe any medications. The sole purpose of the IME is to provide a report to the insurance company about the patient’s condition. A cynical (or realistic and experienced) PIP law attorney might go further and say the purpose of the IME is to provide the insurance company with fodder it can use to deny a claim for reimbursement by saying the treatment provided was not reasonable, necessary, or related to the accident.
During the IME, the doctor will assess the patient’s abilities and functional limitations, often requiring the patient to perform the same movement over and over again to see if the patient responds consistently every time. The patient will also be asked for details about the accident, how the injury has affected the patient’s life, what kind of pain the patient is experiencing, etc. The doctor might also review the treating physician’s treatment records before or after the examination.
After the IME, the doctor will provide the insurance company with a written and signed report that indicates the doctor’s opinion of whether the treating physician’s treatment is reasonable, related to the accident, and necessary. Florida PIP law gives insurers the authority to withdraw payment based on the findings of the IME.
Facts About Florida PIP Law IMEs
Florida Statutes 627.736(7)(A) requires a patient to submit to a mental or physical examination upon the request of the insurer whenever “the mental or physical condition of an injured person covered by personal injury protection is material to any claim that has been or may be made for past or future personal injury protection insurance benefits…” Failure to submit to an IME is grounds for the insurer to deny benefits. Before this can happen, though, the patient’s refusal to submit to an IME or appear at a scheduled IME must be “unreasonable.” The law does not define when a refusal to submit or failure to appear is unreasonable, but it does say that the refusal to submit or failure to appear at two exams raises a rebuttable presumption that the refusal or failure was unreasonable.
The insurance company picks the doctor who conducts the IME and pays all the costs associated with it. The physician must be licensed under the same licensing chapter as the physician whose bills are in question. In other words, an MD must perform an IME if the patient is being seen by an MD, or a DO for a DO, etc. The law also provides other requirements regarding whether the doctor chosen for the IME is in active practice and other qualifications.
The IME should be conducted in the same municipality where the insured is receiving treatment or at some reasonably accessible location. This might be the same municipality or another location in the county within ten miles from the patient’s residence, or as close to the patient’s residence as possible when it is difficult to find a qualified physician to perform the IME.
Get Help With Your Florida PIP Claim Today
The IME is not a medical visit; it is a legal one with legal consequences. The patient can and should be advised or represented by an attorney, and the proceedings can be videotaped and transcribed by a court reporter. Patients have to go, and their benefits (and your rights to reimbursement) are on the line.
If your claim for reimbursement is denied based on the findings of an IME or for any other reason, call Shuster & Saben at 877-511-7829, or reach out to us at any of our many office locations statewide. Our firm is a leader in helping doctors get paid under Florida PIP law, so contact one of our experienced and dedicated attorneys today.