The Difference Between an IME and a Consult

Last week, we looked at Independent Medical Examinations, or IMEs, for Washington workers’ comp claims. IMEs are usually a good thing for claims and consultations can also be beneficial when managed and used correctly.

What is a consult?

Have you ever seen a movie where the patient says, “I’d like a second opinion, doc.”? A consult is similar, but in this case the attending medical provider is the one who would like another provider to take a look. So, the attending refers the patient to a specialist. A consultation may also be required based on administrative rule, as deemed by the Department of Labor & Industries (L&I).

As with an IME, the provider may have questions about one or more of the following:

  • Diagnoses
  • Treatment plan
  • Contended conditions
  • Necessity of surgery

What if there’s a consult on our claim?

As an Approach client, the most important thing to know is that your Approach Retro Coordinator will review the consulting provider and subsequent report to ensure there is no conflict of interest and that the report meets the requirements as outlined by L&I.

In addition, your retro coordinator is reviewing the claim to determine if an IME would be more appropriate. If an IME is more suited to address the questions/concerns on the claim and is scheduled, no consultations will be authorized pending receipt and review of the IME report. This limits further action until the attending provider has the impartial information that he/she needs in order to move forward.

Why do consults require special attention?

While consultations can be beneficial, there are some things to consider:

  • They can happen quickly – before you know it, another provider is involved with the claim
  • In some cases, the specialist may be a colleague of the referring provider, which could become problematic depending on the complexities of the claim
  • Multiple visits can be needed, increasing the cost of the claim along with lost time from work while your employee attends the appointments

Often, medical providers will refer to a specialist when a second opinion is needed regarding therapeutic or diagnostic challenges. L&I often will allow consultations to take place with no prior authorization necessary. Mental health consultations do require prior authorization, as do the scheduling of IME’s.

In short, consults are just one reason that each L&I claim requires close attention. You should also always open mail from L&I immediately, because the contents can have a big impact on the claim along with future costs. Each of our clients at Approach also benefits from a dedicated retro coordinator, who monitors claims so we can address issues right away.

 

 

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