IME Reports: Assuring Excellence! February 21, 2018

Transcription

1 Thanks to you for attending! Providers 74% Claims 22% Attorneys 4% Registrants IME Reports: Assuring Excellence! Christopher R. Brigham, MD with Brock Curry and Ryan Soriano, Esq. Health care Claims Legal Thanks to those who made this possible! Premier Physicians Management Company, LLC International Academy of Independent Medical Evaluators Colleagues / Organizations Sharing Information WorkCentral.com WorkersCompensation.com Managed Care Matters joepaduda.com Gerry Kaplan ImpairMaster.com Brock Curry President, Premier Physicians Management, LLC a California based organization providing administrative services to examiners who perform medical-legal examinations and providing quality IME services to clients. Founder, IME Institute Ryan Soriano, Esquire Board Certified Expert in Workers Compensation law and litigation, representing employers, third-party administrators, insurance carriers, and municipalities, Defense of cases involving public safety law. Nearly two decades of experience with California workers compensation cases. Chris Brigham, MD Internationally recognized as a thought leader on human potential, impairment, and disability. Committed to working with others in the application of evidence-based medicine and best practices to promote function and avoid needless disability. Board-certified occupational medicine, FACOEM, FIAIME. Medical Director, IME Institute, Director of IAIME, Founding Director of ABIME. Author > 275 publications, including Senior Editor of AMA Guides Sixth Edition, Editor-in-Chief Guides Newsletter, and author of Excellent IME Report, Comprehensive IME Systems, and Living Abled. 1

2 9 10 Understand Health and Claims from a Biopsychosocial Perspective 2

3 Learning Objectives 1. Identify common IME report problems and avoid them. 2. Describe current IME report standards. 3. Explain an effective process for producing a quality report. Provide a forum. Agenda Review examples. Identify best practices. Attributes of quality report. Identify common problems. Discuss report types. Explain report elements. Explore evaluation process. Discuss quality assurance. Questions and answers. Zoom - Chat Poll Overall, what is your estimate of the percentage of IMEs that are excellent, i.e. reflect best practices? % Vast majority % More than half % Some 4. <24% Few 5. Not applicable and/or not responding What we see: Poor Quality Work Significant Omissions in Reports Unsupportable Conclusions Inefficient Processes Poor Productivity Dissatisfaction What we want to see: Quality Professionalism Supportable Conclusions Efficient processes Excellent Productivity Satisfaction 3

4 Bad Report Bad Report Bad Report Bad Report Good Report Good Report 4

5 Good Report Good Report Excellent Report Excellent Report Excellent Report Excellent Report 5

6 Poll IME Best Practices Guides Newsletter, September- October 2017 What is your estimate of how often we measure and report customer satisfaction for IME reports? % Vast majority % More than half % Some 4. <24% Few 5. Not applicable and/or not responding Why are the attributes of a quality report and why is this important? Impartial, unbiased. Valid, reliable, defensible. Answers specific questions. Readable. Useful. Common Report Problems Unorganized, incomplete and unclear. Fail to explain. Use terms or abbreviations without explanation. Adjectives and adverbs used unnecessarily. Fail to explain context of statements. Common Problems Must Understand Arena and Client Issues Misuse musculoskeletal and medicolegal terms. Not adequately pruf read, including dictatsun problems, typos, and spilling errirs. Unprofessional appearance. Guides Newsletter January- February 2018 Workers compensation State (California, QME, AME) Federal OWCP Automobile casualty Personal injury (civil litigation) Railroad Medical malpractice Disability 6

7 Medicolegal Report Types Independent medical evaluations Impairment evaluations Medical file reviews Peer reviews Consulting (medicolegal) Verbal only Written: Brief, Detailed Discoverable vs. Non-discoverable IME vs. Conventional Report Aspects (Usual) Independent Medical Evaluation Traditional Clinical Evaluation Goal Case management and evaluation Clinical care Physician Independent Treating or consulting Visits, prior or future, No Yes, possible with physician Physician patient No (or limited) Yes Relationship Visits One Multiple possible Reader Claims professionals, attorneys, Health care providers fact finder History Comprehensive Focused on chief complaints Record review Detailed Limited, if at all Physical examination Detailed, with documentation of negative, positive and nonphysiologic Focused on complaints and diagnoses findings; when applicable, compliant with AMA Guides standards Issues Multiple potential Clinical assessment, evaluation and treatment Report Detailed, written Concise, often electronic record Testimony probability High (depending on arena) Low IME Checklist Report Data Perspective Data In Analysis Data Out Introductory and Descriptive Name Date of birth Date of injury Referring source Date, time, and location of examination Purpose List of all documents History source Time (Table of Contents) Record Review Thorough, complete, and accurate Data sources identified Verbatim quotes Intellectual honesty Chronological order Precise language 7

8 Interview Chief complaint(s) and concern(s) Injury - description of how and when the injury/illness occurred Preexisting status Clinical course Current symptoms Functional status, including Activities of Daily Living Occupational history Interview Past medical history Review of systems Family history Personal and social history Physical Examination Clear, organized Document Observations Height, weight Positive, negative, non-physiological findings Use templates and tables Document consistent with AMA Guides and other applicable standards Other Objective Data Imaging studies Reports Interpretations Electrodiagnostic testing Functional capacity evaluations Laboratory testing Discussion Conclusions must be based on facts of the individual case and science. References provided to evidence based guidelines, specific medical journal articles, reliable sources. Written for non-medical reader. Diagnoses listed numerically (related and not). Disagreements explained. Missing information noted. Treatment Reasonable, appropriate and necessary. Cite relevant evidence-based or consensus based guidelines. Occupational Medicine Practice Guidelines published by the American College of Occupational and Environmental Medicine (ACOEM), Guidelines published by the American Academy of Orthopedic Surgeons, State-specific guidelines (e.g., Colorado Division of Workers Compensation Treatment Guidelines). Official Disability Guidelines (ODG) Evidence-Based Treatment Guidelines published by the Work Loss Data 8

9 Prognosis Based on diagnoses and other factors such as comorbidities. Causation and Apportionment Based on facts, current science and structured process. Reference AMA Guides to the Evaluation of Disease and Injury Causation and/or other relevant literature. Use correct medicolegal terminology. Maximum Medical Improvement Explain when occurred and basis. Synonyms: fixed and stable permanent and stationary stable and ratable Impairment AMA Guides or other criteria must be followed precisely. Specific reference to objectively measurable criteria. Cite method and specific page numbers, table or figures and methodology. AMA Guides follow directives in Chapters 1, 2 and applicable chapters Brigham and Associates, Inc. Work Ability and Functional Status Defined by consideration of: 1. Risk 2. Capacity 3. Tolerance Reference AMA Guides to the Evaluation of Work Ability and Return to Work Recognize the adverse consequences of needlessly removing someone from work. Answers to Specific Questions Verbatim questions should be restated. Explain answers are answered to a reasonable degree of medical probability. Direct answers included, with explanation. References should reflect intellectual honesty. 9

10 Disclosures - Example Poll The above analysis is based on the available information at this time, including the history given by the examinee, the medical records and tests provided, the results of pain status inventories, and the physical findings. It is assumed that the information provided to me is correct. If more information becomes available later, an additional report may be requested. Such information may or may not change the opinions rendered in this evaluation. Comments on appropriateness of care are professional opinions based on the specifics of the case and should not be generalized nor necessarily be considered supportive or critical of the involved providers or disciplines. Any medical recommendations offered are provided as guidance and not as medical orders. The opinions expressed do not constitute per se a recommendation that specific claims or administrative action be made or enforced. Overall, what is your estimate of the percentage of IMEs that you see are compliant with all of these standards? % Vast majority % More than half % Some 4. <24% Few 5. Not applicable and/or not responding Poll In what areas do reports typically need improvement? More than one may be selected. Introductory / Descriptive Data Record Review Interview Physical examination Other Objective Data Clinical Analysis Treatment Analysis and Recommendations Causation and/or Apportionment Analysis Work Ability Assessment Permanent Impairment Analysis Evaluation Process 1.Pre-evaluation 2.Evaluation 3.Post-evaluation How and who performs the specifics of these steps varies, e.g., independent physician, physician working with support organization, or IME broker / company. 1. Pre-Evaluation Referral process Records Record organization and review Preparation of clinical chronology and/or summary Prepare report template Reflects best practices Complete as much as possible prior to evaluation 2a. Evaluation (Prior to Physician Exam) Examinee is greeted and arrival time recorded. Identity of examinee verified. Evaluation process explained to the examinee, and written informed consent obtained. Questionnaires and/or applicable inventories are completed. Staff may interview examinee. Physician reviews studies. 10

11 2b. Evaluation Physician interview Reviews information Closed and opened questions Physician examination Chaperone Document findings Digital photography Examine conclusion Satisfaction survey 3. Post-evaluation Phone Report development Dictation (within 24 hours) Quality Assurance Issued within 5 working days Enclosures (potential) with report: Invoice, W-9, Fee and Payment Policy, CV, articles Post report f/u with client Poll How important is quality assurance in the IME field? A. Very important B. Important C. Somewhat important D. Not important How do you evaluate and manage report quality? Define structured process to assess reports. Evaluate whether report is - Unbiased, impartial, fair. Answered questions. Compliant with best practices. Length, detail, and fee consistent with case. If impairment rated, determine if the rating unsupportable. Provide feedback. IME Checklist What are some steps to improve quality? Choose physician and/or IME vendor wisely. Evaluate credentials (clinical, board certifications, credentials), and report example if unfamiliar with physician. Provide a thoughtful referral letter, define standards, supply records in advance. Critically assess the report. Apply total quality improvement. 11

12 How do we assure customer satisfaction? How do you assure quality? Requesting party Other stakeholders Injured worker Legal counsel (defense and plaintiff) Health care providers Employers Fact finders (judges / hearing officers) Poll Questions and Answers How would you rate your quality assurance program for IMEs and impairment ratings? A. Exemplary, world class B. Very good C. Good D. Fair E. Poor F. Non-existent G. Not applicable cbrigham@cbrigham.com 12