Editor’s note: In response to the Center’s Jan. 21, 2018 report on independent medical examiners, the owner of a Waukesha IME company says doctors offering second opinions in worker’s comp cases can help prevent fraud — and unnecessary medical treatment.
Having read the article you authored, “Injured Wisconsin workers face higher hurdles when seeking compensation,” I found this story to be very personal to me as the operator of a local company providing IMEs in Wisconsin. It is my request that you review the following information for another perspective.
The case about Richard Decker is compelling, and I can see where the reader (including myself) has compassion for a long-term, hard-working employee who had a traumatic injury with significant physical as well as mental components. As an employer myself, I appreciate and value all of my hard-working and loyal employees.
My desire is to show you a side of this industry that is not reflected in your story, based on two decades of service within the IME industry.
In your story, Administrative Law Judge Joe Schaeve said he often knew how certain doctors hired by employers and insurance companies would rule even before opening their reports. “It winds up with the doctor saying not work-related.” Consider the IMEs that are ordered where the report findings are “work-related.” What happens? The claim is paid and it is not disputed, therefore never reaching ALJ Schaeve’s desk. He likely only saw the “not work-related” reports, which would certainly cause his perspective to be skewed. Also consider that the majority of claims adjusters are fairly investigating and paying for treatment of worker’s compensation injuries that do not even require an IME. These claims are not even considered from the data I read in your article. I would contend that the story about Mr. Decker, while tragic, is not commonplace as Judge Schaeve would make the reader believe.
I also tend to disagree with much of the perspective presented by Attorney Luke Kingree. As a “fair-minded and even-keeled” observer, he found as many as 20 LIRC decisions to be clearly incorrect. That combined with him seeing little fraud in 10 years of worker’s compensation law is really difficult for me to believe.
The most obvious evidence is the formation of the Worker’s Compensation & Unemployment Insurance Fraud Unit in December 2016. I attended a presentation by Assistant Attorney General Jake Westman (who is prosecuting fraudulent worker’s compensation claims) and worker’s compensation investigator, Vern Vandeburg. They cited nationwide estimates of worker’s compensation fraud as much as $7.2 billion annually. The types of fraud identified were fake injuries, malingering (refusing to come back to work after an injury) and doctors performing unnecessary procedures, among others.
We consider requests for IMEs on a daily basis. Among the most troubling requests we receive are exams to determine the necessity of treatment. An example would be a physician who lays out an aggressive treatment plan (sometimes unnecessary surgery), that causes an IME to be requested.
In your story, you detailed a Walmart employee located in Chippewa Falls, who strained her arm and shoulder while scanning items on a high shelf. At the advice of her doctor, her spine was operated on unnecessarily. Unfortunately, this example cannot be overstated enough as a scenario we see as an IME provider. This represents an example of excessive and inappropriate treatment, which in the long run, can be detrimental to the employee. Your story looks at the employer and the employee as two components, but I would contend that the treating doctor is often the most troubling third component.
There is a tremendous amount of over-treatment in medicine. Unnecessary spine surgery is front and center; it is a violation of trust of the patient. I’ve seen the term predatory in more than one IME report describing the treatment of the injured worker. Overtreatment in worker’s compensation claims could be a counter argument to your story. When medicine and business come together, not in the best interest of the patient, it could be considered fraudulent. It is now being pursued by Attorney Westman and Investigator Vandeburg. It also can be an incredible cost for the employer. Lost-time worker’s compensation claims make insurance costs rise, to the point where it can be overwhelming for small businesses.
Your article makes the point that doctors traveling into Wisconsin for IMEs may be subjective based on a motive for income. Why would local medical experts not perform IMEs? Wisconsin is unique in that reimbursement for medical treatment of work comp injuries is not subject to a fee schedule and therefore the highest form of reimbursement. In other words, the treating physician is paid the most when an injury is related to work with payment coming from worker’s compensation insurance. Consider Illinois where a majority of the doctors perform IMEs because reimbursement for their patient practice is less and malpractice insurance is higher. The landscape in Wisconsin is unique, some believe that injuries are more often related to work because it is better for business based on reimbursement.
Our company makes a point to develop local medical experts, but it is the narrow road. Busy local doctors can perform a couple, perhaps a few IMEs in a month. IMEs usually represent less than 5 percent of their overall practice. I believe that plaintiff and defense attorneys as well as ALJs (administrative law judges) would agree with this criteria for a credible and respectable medical expert performing an IME.
I don’t take the case of Mr. Richard Decker lightly. Unfairness certainly can take place in this industry by the employer, the employee, the treating doctor and the IME doctor. The point I wish to make is that there is a movement in Wisconsin to combat unfairness within IMEs, with an emphasis on local knowledge, local physicians and objectivity within the process. Our company conducts IMEs for plaintiff attorneys and defense attorneys. A willingness to represent the injured party or the employer is our definition of independence within the IME model.
I asked some of my co-workers for their opinion, they were willing to share two recent cases that show unique value of an honest IME. The first exam was conducted on a gentleman with some diagnostic imaging reviewed in conjunction with the medical records. It was determined by the independent medical examiner that the injured worker was having undiagnosed mini strokes for some time and at serious risk for a significant future stroke. The second case involved a woman who was examined for long-standing shoulder pain, for which the examiner accurately concluded the possibility of bone cancer being the diagnosis. As you can imagine, these two IME reports were well received for their ability to uncover what the treating physicians had not been able to see. One reason an IME report can be insightful is that the doctor is provided with considerably more medical records than a treating physician. An IME doctor often reviews hundreds or thousands of pages of medical records. The review of these records will include prior treatment from multiple providers. The treating physician often does not have the luxury to review that medical history.
I am certain that the desire for IMEs in their creation was for objectivity. There is no reason that we as an industry cannot meet that criteria on each IME that we conduct. I interviewed a client for his requirements of an IME. He wants a medical expert with appropriate training and relevant experience, credibility within the medical community and medical foundation within each report. I would contend that truly objective IMEs are available and quite common within Wisconsin. An honest IME does not make for a good story because the claim comes to a conclusion as a result with no interesting dispute as a result.
The story about Mr. Richard Decker explores possible shortcomings from the IME industry in his particular case. I hope your readers will realize is that there are reputable medical experts who provide objective, well-reasoned reports so that benefits can be considered appropriately. I think the compelling story in Wisconsin related to fraud within worker’s compensation would be the exposure of unnecessary surgery performed by a small community of repeat physician offenders. An interesting yet horrific sideline within that story is be the opioid epidemic in that patient population. Buy a worker’s compensation claims adjuster a cup of coffee and you will learn all about them.
Thank you for considering our alternative perspective of this local IME company that works hard to provide a service that does not make for interesting journalism.
David Crawford owns Crawford Evaluation Group in Waukesha, Wisconsin.
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