Home - Workers' Compensation, IME - Utilization Reviews vs. Independent Medical Exams in Workers Comp: What’s the Difference?

Utilization Reviews vs. Independent Medical Exams in Workers Comp: What’s the Difference?

Utilization Reviews vs. Independent Medical Exams in Workers Comp: What’s the Difference?

If you are looking to prevent liability in case of an employee injury, workers' comp can do that for you. While nobody likes to pay the added cost, it can be beneficial in the long run. By providing healthcare facilities to your employees, you can prevent the possibility of a lawsuit. There is no way to avoid paying for workers' comp. However, there might be ways you can lower the costs of the premiums.

Working with a Professional Employer Organization or PEO can impact your workers' comp payments. Workers' compensation insurance from a Professional Employer Organization can help you lower the costs while keeping your employees safe. Two methods of controlling costs are utilization reviews and independent medical exams. A PEO can guide you through them.

What is a Utilization Review in Workers' Comp?

Utilization Review is the process of ensuring whether the treatment requested by the employee is medically necessary. When workers get injured, they file for workers' comp insurance for their treatment. However, they first need to go through a process to determine if the treatment is necessary.

An independent doctor conducts the Utilization Review. Then, they decide within 5 to 14 days whether to approve, delay, or reject the treatment. When they delay treatment, they wait for additional medical information. 

While there might be differences, the general process of a Utilization Review involves the following steps: 

  1. The employee's doctor requests the insurance company for medical treatment authorization.
  2. The insurance company forwards the request to Utilization Review.
  3. Utilization Review doctor reviews the case and makes a decision.
  4. They send the decision back to the initial doctor.

If the UR doctor finds the treatment unnecessary, treatment costs will fall on the employer. In this case, the injured worker can file an appeal through Independent Medical Review or Independent Medical Exam.

What is an Independent Medical Exam in Workers' Comp?

An Independent Medical Examination (IME) is conducted when the UR doctor denies treatment. A UR doctor chosen by the insurance company reviews the case and gives an opinion on whether the treatment is medically necessary. If they disagree with the initial doctor's diagnosis and deny treatment, the insurance company requests an IME.

The injured worker will likely receive a notification from the insurance company. They will provide the details, such as the date, time, and location of the IME. It is mandatory to attend this meeting. It is noteworthy that this doctor-patient meeting is not like a regular one. There is no confidentiality, and anything the employee says to the doctor can make its way to the report.

One important thing to remember is that the IME is not conducted to receive a second opinion. It is only held to receive an expert opinion on the injuries. The insurance company gathers information from the IME doctor and then decides whether to award the benefits. An IME procedure is not a medical appointment, and the worker is not obligated to follow the doctor's advice.

An IME doctor looks at the following factors during the meeting:

  • The General Appearance of the Worker 
  • Signs of Deception (exaggeration of injuries) 
  • Medical Documents and Reports 
  • Tests and Examinations 
  • Past Medical History

What Is the Difference Between A UR and an IME?

The difference between a Utilization Review and an Independent Medical Examination is straightforward. One determines if the treatment is needed, and the other helps appeal the former decision if the treatment gets rejected.

A UR is a process that helps determine if an injured worker's treatment is even medically necessary. The process includes going through various medical tests. If the UR doctor says it is unnecessary, the injured worker can appeal the decision with the help of an IME. One determines the necessity of medical treatment, the other appeals the decision of the former process.

While the two processes may differ, both can prevent expensive medical charges. Workers' comp is important for all employers. Since nearly every state mandates it, there is no way to escape it. Following the proper measures will help you see how workers' comp insurance can be beneficial in the long run.

The processes, UR and IME, can ensure that your employee's injuries are indeed medically necessary. This can significantly help you prevent increased costs of workers' compensation insurance premiums. If the treatment for the injuries is found unnecessary, you no longer need to worry about paying more insurance money.

How Else Can You Control Workers Comp Costs?

The UR and IME processes are great for lowering the costs of your workers' insurance. However, you can only go so far. To reduce the expenses efficiently, you need to partner with a Professional Employer Organization or PEO. Working with professionals can truly benefit you and save you money.

If you wish to tackle insurance costs on your own, you can certainly do so. However, professionals can do the job more proficiently than the average man, as they have years of knowledge, skills and experience. They can provide peace of mind by providing expert advice and assistance. You will gain access to their special resources and obtain top-notch guidance throughout the process.

What is a PEO?


Workers' Compensation, IME