Medical and related services

Overview

An independent medical examination (IME) is an assessment conducted by an appropriately qualified and experienced medical practitioner to help resolve an issue regarding injury or claims management. An insurer may direct a worker receiving weekly payments of compensation to attend an independent medical examination. The utilisation of an IME should be carefully considered and avoided wherever possible as referral can cause concern and tension for the worker and may have a negative impact on a worker’s recovery and experience in the workers compensation scheme.

This guidance considers:

• the mandatory requirements for insurers when referring a worker for an IME
• communication with the independent medical examiner
• conduct of an independent medical examiner
• release of the report
• fees and invoices
• complaints about independent medical examiners.

Mandatory insurer requirements when using an independent medical examination

Part 7 of the Workers Compensation Guidelines (the Guidelines) specifies the requirements for arranging independent medical examinations.

The mandatory obligations for insurers when they require a worker to attend an IME outlined in the Guidelines deal with:

• the reason for referral, including that referral for an IME is appropriate when information from the treating medical practitioner(s) is inadequate, unavailable or inconsistent, and the referrer is unable to resolve the problem directly with the practitioners (see part 7.1 of the Guidelines)
• qualified and appropriate independent medical examiners (see part 7.2 of the Guidelines)
• conflict of interest (see part 7.3 of the Guidelines)
• special requirements, which may include the location of the IME and relevant travel restrictions (see part 7.4 of the Guidelines)
• notification to the worker and what is to be included in the written advice to the worker (see part 7.5 of the Guidelines)
• further independent medical examinations (see part 7.6 of the Guidelines)
• unreasonable request (see part 7.7 of the Guidelines)

When considering treatment requests, the insurer is expected to work collaboratively with the worker and their treating practitioner(s). If the insurer is concerned that the treatment requested will not lead to optimal health outcomes, they should discuss this with the treating practitioner in the first instance.

If the issue remains unresolved, a second opinion may be considered and offered to the worker before a referral for an independent medical examination. The referral for a second opinion is to be made by the nominated treating doctor.

Whenever possible, the insurer should contact the worker first by phone to discuss the need for an independent medical examination.

An independent medical examination should only be considered after these steps have been taken.

Communication with the independent medical examiner

The insurer should provide the independent medical examiner with adequate and relevant information to support the referral. This includes:

• a detailed reason for referral, with tailored questions the insurer requires to be addressed
• contact details of the worker and nominated treating doctor
• relevant documentation from the case file to help the examiner’s understanding of the claim and to assist in answering the questions to be addressed. Relevant documents may include:
  • the claim form
  • certificate/s of capacity
  • witness reports
  • employer report of injury
  • reports of treating practitioners (doctor(s), allied health)
  • radiological films/reports where applicable
  • medical investigation reports
  • rehabilitation and functional assessment reports
  • job descriptions and duty statements
  • details of work with other employers and details of other settlements or awards.

Documents should be provided to the independent medical examiner at least ten working days before the arranged appointment. They should be provided in a manner that facilitates review by the independent medical examiner. This means attachments, grouped according to information type and in chronological order, with no duplicate reports or information.

Independent medical examiners are not able to order additional radiological or similar investigations, so the results of all existing relevant investigations are to be made available to the independent medical examiner.

Conduct of an independent medical examiner

Practitioners should adhere to the Medical Council of NSW’s Guideline - Medico-Legal consultations and examinations during examinations.

If the worker provides the independent medical examiner with any additional information at the time of the examination, this information is to be noted in the examiner's report.

Independent medical examiners must also comply with Part 4 of the Guidelines for the Provision of Relevant Services (Health and Related Services).

After the independent medical examination

Consideration should be given to releasing the report to the worker as a matter of course (see Standard of practice S2. Worker access to personal information).

If the worker requests a copy of the report under the Health Records and Information Privacy Act 2002 the insurer is required to comply with the relevant legislation and may be required to release the report (unless one of the exemptions apply).

If the insurer feels that the release of the report could be detrimental to the worker’s wellbeing, they are to advise the worker in writing that they can talk to their nominated treating doctor regarding the contents of the report.

The insurer is encouraged to talk with the worker about the action being taken following receipt of the examiner’s report. This might be to advise that a liability decision has been made, or to advise no further action is required.

Fees and invoicing

Fees

Fees for independent medical examinations are set out in the latest Fees Order. The Fees Order specifies:

• the maximum amount payable for medical services carried out for workers compensation claims
• the codes providers are to use
• what various services include.

The degree of complexity of the examination and the fee payable should be agreed with the independent medical examiner when making the appointment.

Pre-payment for reports or services is not permitted.

Invoices

Invoices must be submitted within 30 calendar days of the examination (see also Insurer guidance GN 4.3 Invoices and reimbursements).

Working toward best practice

Insurers should call the practitioner if they have questions regarding an invoice. Errors or queries can often be resolved quickly over the phone, and this is beneficial to all parties. If telephone contact is unsuccessful, then an email or letter should be sent seeking clarification.

Insurers should always attempt to resolve an issue with an invoice, rather than decline to pay the invoice without first seeking clarification.

Complaints about independent medical examiners

Complaints about the conduct of independent medical examiners should be made to the referrer in the first instance.

If a complainant is dissatisfied with the referrer’s response, they can contact:

• SIRA on 13 10 50
• Independent Review Office on 139 IRO/13 9476
• the Health Care Complaints Commission (HCCC) on 1800 043 159
• the Australian Health Practitioner Regulation Agency (AHPRA) on 1300 419 495.