COVID-19 and IMEs

You are receiving this email because you are an approved IME Provider.

The department is providing additional information below as continuing clarifications/changes in response to IMEs and COVID-19 questions we receive. We continue to have discussions with stakeholders and to update processes. Watch for further details in future communications.

Clarifications / Changes

DEFINITIONS:

Forensic Exam – Agreed and authorized by the CM, addressing questions, and then authorized for payment by Teri Baughman

Record Review – A chronological summary of the records reviewed in advance of an exam where the worker was a “no show” and the exam was rescheduled with a different IME firm, or an exam that was “canceled” and rescheduled with a different IME firm. The record review is documentation of the work completed in preparation for the exam, and does not address questions asked to be addressed during a full exam. If a panel/examiner believes a forensic exam is appropriate, this must be authorized by the CM first (see “Forensic Exam”).

Revised IME workflow, through July 3, 2020, includes the addition of firms being able to bill for a Record Review and Telemedicine options (details included below)

No Show/Late Cancelation/Record Review Options:

1. Bill for a “No Show” under 1111M or 1120M (see billing requirements) OR;
2. Bill for a “Late Cancelation” under 1134M or 1135M (see billing requirements) OR;
3. Bill for a Record Review** under 1124M “Other, by Report” – and submit the Record Review documentation to L&I.  Preauthorization for a Record Review must be obtained by contacting Teri Baughman .
4. The Forensic process will not change, i.e., this type of request is typically generated by the Claims Manager (CM) and typically involves cases where the worker is too ill to go to an IME or in the case of fatality claims.  However, if the IME firm feels this may be an option, they can request authorization through the CM during this time.  Although a forensic exam must first be authorized by the CM, Teri Baughman needs to be notified of the CM approval so that the 1124M payment can also be authorized.  Forensic requests have specific questions for the examiner to answer (while a Record Review does not include answering questions).  During this COVID-19 emergency, the CM will look to potentially be more liberal with Forensic requests, including the possibility of re-openings.

Telemedicine IME Options – The list below is based on whether the specific area requires significant information from the physical examination that is essential to the evaluation.  If the examiner has ways to obtain the required information remotely, L&I could defer to that circumstance on a case-by-case basis.  Telemedicine may be appropriate in the following cases, based on individual circumstances, when both audio and video connections are available:

• Mental Health
• Dermatology
• Speech – when there is no documented hearing loss
• Kidney Function
• Hematopoietic System (blood)
• Endocrine

Requirements for IMEs conducted via telemedicine include:

1. Examiner believes exam is appropriate to conduct via telemedicine.
2. All parties are in agreement with a telemedicine IME (i.e., claims manager, worker, representative, employer, etc.).  This agreement includes location of the worker and/or examiner (i.e., home, IME firm site, etc.).
3. Telemedicine IMEs would bill the place of service -02 for “telehealth” so as to track and be able to do a retrospective review.
4. Follow the system requirements documented in Chapter 10 of the Medical Aid Rules and Fee Schedule (page 24), which are: “Telehealth services and teleconsultations require an interactive telecommunication system, consisting of special audio and video equipment that permits real-time consultation between the patient and the consultant. Providers are responsible for ensuring the complete confidentiality and privacy of the worker is protected at all times.”