SCOPE

WHAT IS A DISABILITY EVALUATION SPECIALIST AND INDEPENDENT MEDICAL EXAMINER?

               

PURPOSE:  To create an understanding of what a Disability Evaluation Specialist and Independent Medical Examiner is and how to facilitate the utilization of such skills in conjunction with all other parties including, but not limited to attorneys, insurance companies and government agencies, for the effective and expedient resolution of legal, governmental and insurance issues dealing with personal injury, environmental exposure, Workers’ Compensation and Social Security.

I.   DEFINITIONS:

• Disability Evaluation Specialist – a healthcare professional using a standardized approach to the identification, evaluation and rating of impairment and disability (AADEP). 

• Independent Medical Examiner – uniform standards of competency for licensed physicians who conduct independent medical examinations (ABIME). 

• Impairment – AMA Guides to the Evaluation of Permanent Impairment, 1997 Florida Impairment Rating Schedule.

• Disability – Americans For Disability Act, job descriptions.

• Future vocational and/or medical rehabilitation requirements.

• Exacerbation.

• Aggravation.

• Maximum medical improvement (MMI).

• Functional capacity evaluation (FCE).

• Patient/examinee.

• Patient (examinee), doctor, attorney, insurance company relationship.

 II.  MEDICAL EXAMINATION:

• Initial 

• Interim

• Final

• Independent medical evaluation

• Update to final evaluation (medical evaluation)

• Amended final evaluation (medical evaluation)

• Point of clarification

III. SCOPE, i.e., Vendors:

• Personal injury – independent medical evaluations, attorneys, insurance companies. 

• Workers’ compensation – MMI, managed care, required IME.

• Social Security – (Patient’s attorney) Facilitate and/or eliminate the appeals process; (Social Security Administration, Florida Department of Labor and Security) review  and/or  establish impairment, restrictions. 

• Insurance Companies

  1.               Review reasonable, necessary and appropriate 

  2.                Maximum medical improvement  

  3.               Treatment course, prognosis, improvement

• Pension, disability programs – Review disability status regarding maintenance of a disability program.

IV. TYPE OF EFFORT:

• Simple – often  soft tissue – clear causality without preexisting conditions – treated appropriately within an anticipated treatment period.

• Moderate – involves several variables i.e., preexisting, patient hasn’t followed treatment plan, many doctors, missing medical records and/or pertinent history for a complete report. 

• Complex – history of several injuries, abundance of medical records, patient victimization, somatatization, psychiatric manifestations, questionable liability(slip and fall, environmental, development post traumatic myofascial or fibromyalgia syndrome, apportionment, causality, possible elements of malpractice or poor treatment outcome, old case (over 18 months), significant physical injury. 

V.           TYPES OF CASES:

• Mental

• Cosmetic 

• Soft tissue 

• Head

• Psychiatric

• Organic 

• Somatoform

• Post traumatic myofascial pain/fibromyalgia pain syndromes

• Temporomandibular joint syndrome

• Environmental exposure (respiratory, skin)

• Toxicology

• Adverse reactions to medications, inappropriate labeling of medications

VI.   DISTINGUISHING FEATURES OF A MEDICAL EVALUATION BY A DES, IME:

• Attention to preexisting conditions with quantification with regard to improvement, physical limitations and present therapy predating the injury in question.

• Attention to physical restrictions and limitations before and after the alleged injury.

• Detailed analyses of diagnoses with special attention to objective findings and specialist’s evaluations.

• Complete review of all consultants’ reports with logical marginalization. 

• Clear report (anatomy of a report);

• Appropriate header and footer with specific identifying information and number of  pages with total  number of pages.

• Chief complaints.                          

• Age and summary of injury.                                              

• Treatment course.

• Past medical history.

• Social history (work, hobbies, history SSI, habits, marital status, education).

• Family history.

• Review of systems.

• Physical examination (objective clinical findings… pinprick, range of motion, Tinel, Phalen’s, Adson’s, observation, palpation).

•  Diagnostic studies (chronological, identification of medical specialty, diagnoses,  salient professional  opinions, "media is the message."

•  Assessment – Diagnoses with documentation of appropriate objective diagnostic studies and date (towards the top) followed by all additional diagnoses including  status post, history of and additional objective findings.

• Permanent functional impairment rating.

• Overall discussion with regard to causality, preexisting, apportionment, medical certainty, objective and clinical criteria.MMI, treatment recommendations, review of consultants’ opinions and recommendations.                

• Physical limitations and/or restrictions, recommendations regarding vocational rehabilitation, functional capacity evaluation.

• Additional recommendations with regard to diagnostic studies and review of  injury with effect on  establishing and/or modifying the permanent functional impairment rating.

• Does not have –

        1.                Editorializing.

        2.                Opinion of treatment of other professionals.

VII.   HOW SUCH A REPORT MAY DIFFER FROM PREVAILING REPORTS FROM CHIROPRACTORS, NEUROLOGISTS, ORTHOPAEDISTS, PHYSICAL REHABILITATION SPECIALISTS AND OTHERS:

Essentially nothing new under the sun though patients are seeing more physicians and medical information is often skewed to the consultant’s specialty.

• Family practitioner relies on experts.

• Familiarity with impairment and disability guidelines as per the AMA Guides to the Evaluation of  Permanent Impairment, 4th Edition.

VIII.  ADDITIONAL SERVICES TO OBJECTIFY A TREATMENT END POINT AND COORDINATE THE  PROJECTION OF FUTURE VOCATIONAL AND MEDICAL REHABILITATION NEEDS, INCLUDING COST:  (helps to eliminate work within the attorneys’ offices)

• Functional capacity evaluation

• Vocational rehabilitation evaluation

IX.   RANGE OF COST FOR THE MEDICAL EVALUATION:

•   Simple

•   Moderate

•   Complex

•  Functional capacity evaluation

•   Vocational rehabilitation evaluation

X.    GENERAL COMMENTS:

• Malingerer

• pet peeve (reports not properly labeled

• merry-go-round report)

• range of treatment within two years (MMI varies from state to state)

• work – no work

• everything written

• decision analysis

• formats

• readability

• presentation in court

• discussion of various reports.

XI.  SUMMARY:

          Essentially attempt to extract, develop and/or frame the entire medical/legal context with regard to the medical perspective based on consistent history, physical examination, objective findings and consensus of medical specialists with an opinion of causality, impairment, apportionment, physical restrictions and additional diagnostic recommendations, the purpose of which facilitates a just and appropriate decision with regard to the resolution of the patient’s medical/legal claim.

               

THE HEALTHPLACE

A PRIVATE MEDICAL PRACTICE OF DAVID P. KALIN, M.D., M.P.H.

P.O. BOX 6009

PALM HARBOR, FL 34684

TEL 813.966.1431  FAX 813.925.1932

drkalin@drkalin.com

 

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