Insights from an Independent Medical Examiner April, 2025
At our practice, we understand that most injured workers simply want their lives back—to return to the day before their injury. Unfortunately, the path to recovery is often complicated by a range of medical and administrative issues that drive up workers’ compensation costs and delay return to work.
As a physician who performs Independent Medical Examinations (IMEs), I’ve seen firsthand how avoidable missteps can turn a straightforward injury into a complex, expensive claim. Below are some of the key medical factors that can quietly inflate liability and prolong case resolution.
1. Incomplete Injury History: The Missed Opportunity of the First Report
The First Report of Injury is often the last meaningful interaction between the employer and the worker until return to work. Despite its importance, this report is rarely integrated into the medical record. Inaccurate or vague reporting at this stage can lead to confusion, delayed treatment, and extended disability.
2. Diagnosis Creep: Expanding the Scope of the Claim
It’s common for symptoms to evolve over time. However, when unrelated conditions are later added to a claim without clear medical correlation, this "diagnosis creep" can muddy causation, expand the scope of treatment, and drive up costs unnecessarily.
3. Treatment Delays Due to Authorization Gaps
Delayed approvals for procedures and therapies can lead to treatment gaps that prolong disability. For example, a rotator cuff repair may need 3–6 months of rehab, yet authorizations are sometimes issued in 4-week blocks—each requiring new approval. These interruptions slow recovery and often compromise outcomes.
4. Preexisting or Subsequent Injuries
Accurate assessment of prior and subsequent injuries is critical. Preexisting conditions may be aggravated by a workplace injury, and additional injuries during recovery may alter the treatment plan. These details are sometimes hidden in physical therapy notes or overlooked entirely, leading to misguided care.
5. Inflated Costs from Surgical Unbundling
Some providers submit bills as if each procedure was done in isolation, rather than applying standard reductions for multiple procedures performed in the same session. This unbundling significantly inflates surgical costs and often goes unnoticed without expert review.
6. Disconnected Pain Management
Pain management specialists often focus on procedures rather than causation. Without a thorough understanding of musculoskeletal injury, treatment can devolve into a cycle of injections with no clear therapeutic goal. A targeted, evidence-based plan is essential for both recovery and claim resolution.
7. Provider Changes Late in Treatment
As recovery slows, patients may seek out new therapists or providers out of frustration. Unfortunately, switching providers at the end stage of treatment often restarts therapy without improving outcomes. This adds cost and delays maximum medical improvement (MMI).
8. Reluctance to Declare MMI
Some providers are hesitant to acknowledge that an injury has reached its maximum medical benefit, especially if symptoms persist. In these cases, treatment may continue beyond what is evidence-based, delaying resolution and increasing cost.
A Medically Sound Approach to Case Resolution
At our practice, we approach each IME with a clear understanding of injury mechanisms, functional impact, and causality. Our goal is to provide objective, timely, and defensible evaluations that help move cases toward resolution—while recognizing the human side of every claim.
Ralph T. Salvagno MD
Medical Director , Main Street IME Physicians LLC