Fourth Quarter 2018
By: Stephen P. Murray
Question: Under what circumstances do you recommend a Utilization Review (UR) or an Independent Medical Examination (IME) in an otherwise compensable claim?
Short Answer: In Kansas, we recommend using IMEs in an otherwise compensable claim when we want a determination of permanent impairment and/or permanent restrictions, whether medical treatment is reasonably necessary, and whether maximum medical improvement has been reached. In Kansas, utilization and peer review can be used to dispute all or potions of a bill for services rendered for the care and treatment of an employee under the Kansas Workers’ Compensation Act, however, it is generally done in conjunction with a hearing coordinated by the director.
Independent Medical Examination (IME)
In Kansas, if an injury is compensable, which means that a workplace accident or activity was the prevailing factor for the current injury or symptoms, there are still several situations that we recommend obtaining an IME in a case. Although generally the treating physician’s opinion is given the most weight by the Court, there are often situations where a treating physician either will not provide a permanency rating or will defer to another physician to provide additional recommendations. In both of these situations, we recommend scheduling an IME to have those issues addressed.
In addition to this, we recommend using an IME when an additional injury is claimed to have “sprouted out” of a compensable injury, such as an employee that seeks treatment for a shoulder injury and later claims that they are also experiencing memory loss and headaches. In a situation like this, an IME with a qualified physician would be recommended to both provide a causation opinion and an opinion on permanent restrictions and impairment, should the employee be at maximum medical improvement.
Utilization Review (UR)
We recommend following the utilization/peer review process when medical treatment bills are disputed pursuant to Kansas Revised Statute 44-510j. In Kansas, in order to use a utilization review, the employer or carrier must notify the service provider within 30 days of receipt of the bill the specific reason for refusing payment. Once a formal hearing on the matter is set, the director has the right to conduct a utilization review of the disputed bill or bills prior to the hearing. The formal hearing is conducted by hearing officers, the medical administrator, or both as appointed by the director. During the formal hearing each party has the opportunity to provide evidence by way of witnesses, including expert witnesses, and any other evidence relevant to the matter.
Practice Tip: In Kansas, it is important to use the Act as it is written to the benefit of the employer by obtaining medical opinions whenever possible to challenge compensability. If an employee suffers from a pre-existing medical issue, using an IME to have that pre-existing injury analyzed for causation is extremely important because in Kansas, unlike many states, for an injury to be compensable, a workplace accident must be the prevailing factor in the arising of the current injury or symptoms. Even when an injury on the surface appears to have been caused by a workplace accident in Kansas, it is important to gather prior medical records and submit those to a physician to obtain their opinion on causation.