Claims Review

 

Claims have different requirements, life cycles and turn around times. Our experts address requirements case-by-case and state-by-state.

Evaluating medical claims can be challenging, especially as new technologies and medications impact protocols.Typically guidelines dictate when to request an IME service. The timing of the referral varies, satisfactory outcomes being the goal.

Here are some considerations when determining whether an IME, Peer Review or Bill Review service might be appropriate.

Chiropractic and Physical Therapy – Independent Medical Examination

  • More than three treatment modalities per visit
  • Treatment continues without documented improvement
  • Daily chiropractic treatment for a low impact accident in excess of one week

Medical Records – Independent Medical Examination or Medical Record Review

  • Finding not consistent with mechanism of injury
  • Diagnosis not supported by documentation
  • Inconsistency between claimant interview, notes and doctor report

Radiology– Independent Medical Examination or Medical Record Review

  • Diagnostics for parts of the body not mentioned as injured
  • Repeat x-rays after soft tissue injury has been established
  • No x-rays with a diagnosis of fracture

Provider Bills – Bill Review Service

  • Diagnosis inconsistent with treatment
  • Charges for services not itemized
  • Routine treatment provided on days the facility isn't open typically

No two claims are alike and can be complicated. Unsure if or which IME service is needed, contact an account executive at a local service center.

 

ExamWorks Group, Inc. • 3280 Peachtree Road NE • Suite 2625 • Atlanta, GA 30305
Phone: 404.952.2400 • Fax: 404.846.1554
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