The Components of an Objective IME

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Brian Randall
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1 The Components of an Objective IME Presented By: Lee H. Doppelt, PhD Brought to you by:

2 Today s Topics Appropriate and ethical communication with IME providers IME providers standards of conduct requirement OAR Concerns during the exam - ORS OAR OAR IME Complaint Process & Investigations Understanding The Neuropsychological Evaluation

3 Appropriate and ethical communication between claims professionals and IME providers Be honest in all communications. Never offer a fee for services dependent upon the IME provider writing a report favorable to the insurer. The IME provider is expected to reach conclusions that are based on facts and sound medical knowledge and within the qualifications of the examiner. (see guidelines of conduct) It is appropriate for the IME provider to only address conditions the worker has claimed. Don t ask the IME provider to address conditions the worker has not claimed. Phrase your questions to the IME provider in a way that won t appear to lead him/her to a conclusion. Remember the IME provider s role is to provide an independent, unbiased, and objective evaluation to establish medical facts about a worker s physical condition. Don t ask leading questions.

4 Appropriate and ethical communication between claims professionals and IME providers Examples of leading questions: Example: If there are work restrictions and they are permanent, wouldn t (worker) be considered medically stationary? Instead: If there are work restrictions and they are permanent, is (worker) medically stationary? Example: If (worker) is not medically stationary at this time, do you believe it is because of preexisting conditions? Instead: If (worker) is not medically stationary at this time, please explain. Example: There appears to have been a motor vehicle accident that occurred in October, 2002 affecting at least the back if not the shoulder. (Accepted condition = L shoulder dislocation) Instead: Worker was in a motor vehicle accident in October, 2002 and injured his back. Example: It appears that the prior radiographs were essentially normal and the current MR scan shows unrelated changes. Instead: Prior radiographs were reported to be essentially normal and the current MR scan shows unrelated changes. Example: Do you agree that all of the loss of ROM is due to an unrelated condition? Instead: Describe ROM findings due to the accepted condition.

5 Appropriate and ethical communication between claims professionals and IME providers The IME provider is expected to write an unbiased, independent, objective evaluation. Don t ask the IME provider to reword or rephrase the report. Don t attempt to influence the IME report. Don t tell the IME provider not to write or send the report. The rules require the provider to send the insurer a report. If you need clarification, it is fine to ask follow-up questions.

6 IME providers standards of conduct requirement See OAR Handout Before the Exam Remind the examinee of the party who requested the examination. Explain to the examinee that a physician-patient relationship will not be sought or established. Tell the examinee the information provided during the examination will be documented in a report. Review the procedures that will be used during the examination. Advise the examinee a procedure may be terminated if the examinee feels the activity is beyond the examinee s physical capacities or when pain occurs. Answer the examinee s questions about the examination process.

7 IME providers standards of conduct requirement See OAR Handout During the Exam Refrain from derogatory comments or personal opinions. Examine the condition being evaluated sufficient to answer the requesting party s questions. Let the examinee know when the exam has concluded, and ask if the examinee has questions or wants to provide additional information.

8 IME providers standards of conduct requirement See OAR Handout Be honest in communications Respect rights of examinees; treat with dignity and respect Identify yourself to the examinee as an IME physician. Verify the examinee s identity. Provide the requesting party a timely report. Reach conclusions based upon fact and sound medical knowledge for which the physician is qualified to express an opinion. Address conflict in professional manner Never accept a fee that is dependent upon writing a favorable report to the referring party Maintain confidentiality

9 Concerns during the exam - ORS OAR OAR Observers Unpaid observers may be present during the exam. The examinee must complete an observer form 3923A, IME observer Form, acknowledging that the worker understands: The IME provider may ask sensitive questions during the exam in the presence of the observer. Observers cannot participate in or interfere with the exam If the observer interferes with the exam, the IME provider may stop the exam, which could affect the worker s benefits. The observer must not be paid to attend the exam. A person receiving any compensation for attending the exam may not be a worker s observer. The worker s attorney or any representative of the worker s attorney may not be an observer. Approval is required on psychological exams by the Physician Recording Exams Only allowed if the physician approves Invasive Procedures Physician must explain the risks and explain the worker has the right to refuse the procedure. Invasive means one that breaks the skin or penetrates, pierces, or enters the body using a surgical or exploratory procedure (e.g., by a needle, tube, scope, or scalpel.) Form must be given by the physician to the worker If procedure is refused it will not affect workers compensation benefits

10 Concerns during the exam - ORS OAR OAR Location Disputes WCD must be notified within 6 business days from the mailing date of the appointment notice if the worker wishes to request review by WCD. When a worker objects to the location of an IME, the worker may request review before the director within six business days of the mailing date of the appointment notice. The request may be made in-person, by telephone, fax, , or mail. The director may facilitate an agreement between the parties regarding location. If necessary, the director will conduct an expedited review and issue an order regarding the reasonableness of the location. The director will determine if travel is medically contraindicated or unreasonable because: The travel exceeds limitations imposed by the attending physician, authorized nurse practitioner, or any medical conditions; Alternative methods of travel will not overcome the limitations; or The travel would impose undue hardship for the worker that outweighs the right of the insurer to select an IME location of its choice.

11 IME complaint process and investigations The workers compensation division has received the following worker complaints regarding unprofessional behavior by some IME providers: Asking the same questions multiple times after the worker has already answered. Trying to convince or persuade the worker of the provider s opinions or conclusions. Using a position of power to manipulate the worker s response to fit the provider s expectation.

12 IME complaint process and investigations Minimizing the worker s pain complaints to achieve a better range of motion measurement. Not giving the appropriate empathy for and not recognizing the worker s fears and anxiety. Not actively listening and responding appropriately to the worker s concerns and questions. The workers comp division investigates worker complaints of this nature and will determine the appropriate action, which may include sanctions or removal of the IME provider from the department s IME list. During the investigation the director may contact you regarding the allegation.

13 IME complaint process and investigations The worker may go online at to complete the Workers Compensation Division survey or if they have a complaint about the IME provider. If the worker does not have access to the internet they may call the Workers Compensation Division at for assistance.

14 Understanding The Neuropsychological Evaluation LEE H. DOPPELT, Ph.D. Licensed Psychologist Medical and Consulting Psychology Clinical Neuropsychology

15 Introduction Who Am I? Training Background

16 What is a Neuropsychological Evaluation? Comprehensive assessment of cognitive processes (structural and functional integrity of the brain). Integrates genetic, developmental, environmental data with testing data. 3 Components 1. Review of records (medical, law enforcement, employment, school etc.). 2. Clinical interview. 3. Administration of tests that measure cognitive abilities as well as mood and personality. a) Cognitive symptom validity measures. b) Standardized testing procedures.

17 Why do a Neuropsychological Evaluation? Answers general questions (relative to his/her peers and self) 1. Current cognitive abilities. 2. Identify cognitive strengths and weaknesses. 3. Obtain a baseline for future evaluations. 4. Assess if cognitive symptoms are related to injury/brain insult or other factors?

18 Why do a Neuropsychological Evaluation continued Confirm or clarify a diagnosis (closing evaluation). Provides data to specific questions (e.g.): 1. When can I go back to work? 2. Can I start driving again? 3. What kind of restrictions/accommodations do I need to function? a) Work b) Home c) School

19 Why do a Neuropsychological Evaluation continued Provides a road map of customized recommendations. 1. Treatment (referrals to other providers (neurologists, orthopedists, psychiatrists, cognitive rehabilitation specialists, etc.) 2. Therapy (psychologists, social workers, counselors, speech therapists, occupational therapists, vocational counselors) 3. Medications

20 Neuropsychological versus Standard Psychological versus Psycho-educational Evaluations? Psycho-educational evaluations (achievement: reading, writing, math, etc.) 1. Schools 2. Employment Standard psychological evaluations (3-5 hours) 1. Focused on general intellectual functioning 2. Personality functioning Neuropsychological evaluations (6-8 hours) 1. Potential complications a) ESL b) Fatigue c) Mental status

21 Typical skills and abilities measured in Neuropsychological Evaluations: General intelligence Attention and concentration Learning and memory (verbal and visual) Auditory and visual processing Language and reading skills Visual and spatial/constructional skills Gross and fine motor skills Executive functioning 1. Problem-solving 2. Abstract thinking 3. Planning 4. Initiation Emotional and personality functioning

22 When to refer for a neuropsychological evaluation (Workers Compensation)? Assessment of neurocognitive abilities following a traumatic brain injury (TBI or mtbi) Assessment of neurocognitive abilities following toxic exposure Assessment of neurocognitive abilities to assist in the development of rehabilitation and/or management strategies for persons with diagnosed neurological or psychological disorders or degenerative disorders Assess differential diagnosis between psychogenic and neurogenic syndromes Monitor the progression of cognitive impairment secondary to a neurological injury/disorder

23 Workers Compensation Neuropsychological Evaluations Traumatic brain injuries (TBI) Mild traumatic brain injuries or concussions (mtbi) Toxic exposure Psychiatric disorders impacting cognitive functioning

24 Traumatic brain injuries (TBI) or mild traumatic brain injuries (mtbi) or concussion Rapid acceleration or deceleration to the brain following a blow to the head or as a result of violent shaking of the head. 1. Motor vehicle accident 2. Fall 3. Contact with object or projectile 4. Sports Typical symptoms 1. Physical (headache, nausea, dizziness, visual disturbance, balance issues, photophobia, numbness or tingling, vomiting) 2. Cognitive/thinking issues (feeling mentally foggy, concentration problems, memory problems, slower thinking speed, slower processing speed) 3. Emotional issues (irritability, sadness, emotional lability, anxiety, depression) 4. Behavioral issues (sleep issues, exercise issues, social issues, activities of daily living issues)

25 Traumatic brain injuries (TBI) or mild traumatic brain injuries (mtbi) or concussion continued Assessment of brain injury 1. Medical records (GCS score, PTA scores including both anterograde amnesia and retrograde amnesia, loss of consciousness, symptoms) 2. Neuropsychological testing protocols Recovery expectations 1. Post-concussive syndrome 2. Alternative explanations

26 Understanding the Neuropsychological Evaluation report Typical components 1. Reason for referral 2. Specific questions asked 3. Relevant background information a) Medical history (both historical as well as self-report) b) Mental health history c) Developmental history d) Drug and alcohol history e) Relationship history f) Work history g) Legal history

27 Understanding the Neuropsychological Evaluation report continued 4. Procedures 5. Test results a) Cognitive (typically reported in terms of percentiles or ranges) 1. Cognitive symptom validity (malingering or exaggeration) b) Emotional/personality 1. Validity 6. Diagnoses 7. Impressions/Summary 8. Conclusions/responses to specific questions

28 How to prepare the examinee for a Neuropsychological Evaluation? Good nights sleep. Give yourself plenty of time. Eat something before and bring something for lunch. Complete questionnaires that were mailed to you and bring them to the evaluation. Take medications as directed. Bring corrective lenses and hearing aids, if appropriate. Ask for breaks as needed.

29 Alternative evaluations Psychiatric (do not administer objective psychological tests) Neurological Imaging

30 For More Information or to Schedule With Lee H. Doppelt, PhD Call:

Mild Traumatic Brain Injury (mtbi): An Occupational Dilemma

Mild Traumatic Brain Injury (mtbi): An Occupational Dilemma William H. Cann, MD MPH Occupational Medicine Trainee Occupational Medicine Trainee University of Washington Disclosures None This presentation