A while back I asked the list for assistance with a patient and friend who was facing an independent medical (IME) exam for approval for a bone bridge procedure. The challenge facing us was to gather information about the Ertl procedure to present to the doctor performing the IME, because familiarity with the surgery was not guaranteed. Today we have just received word that the surgery has been approved. The case did not have to go to an official hearing because the doctor performing the IME (read insurance company’s doctor) agreed with the evidence presented. I wish to sincerely thank all who responded.
I received several queries from practitioners with patients in similar situations who asked to be kept updated. It is because of those requests that I outline what I believe assisted in approval process.
First off, it helps to a world class surgeon with an excellent support staff as the attending physician. The approval process is a paperwork game and it certainly helps if the doctor’s office produces excellent documentation.
Tony Barr, of the Barr foundation was an excellent resource. He was prompt and helpful in sending both the patient and physician version of the Ertl instructional video, Beyond the Bridge. This video was given to the doctor who preformed the IME.
Ohio Willow Wood provided an excellent folder of succinct information about the Ertl procedure that was given to the doctor performing the IME. In this folder were printouts of X-rays that showed the bone bridge. I would have preferred to have actual X-ray film to show but the paper printouts were sufficient.
I purposefully avoided including anecdotal evidence, uncited claims and unreferenced studies, even avoided supportive letters from prosthetists. As persuasive as those things may be, I wanted the documentation to be a clinical and concise as possible for review by a busy medical doctor.
Patient documentation was the final key to getting approval. We have been involved in this worker compensation case for twelve years. Independent medical exams are an accepted part of our lives. We no longer view them as an adversarial encounter. We now try to assist the IME doctor in navigating the huge mound of patient charts related to this case. One of the most effective things that we did about six years ago was to create a brief outline of everything related to this case. It is a document, with selected color photographs, that details and dates every doctor’s visit, prosthesis, surgery, approval difficulties, etc. It started out as a seven page document and now runs about thirty. The IME doctors look relieved when this document is handed to them as it is certainly an easier read (and probably more accurate) then the multitude of disjointed charts from multiple physicians. Long term complaints, such as related to the bone bridge revision, are tracked over time !
in this
outline. Suffice it to say that we have never lost an issue with the insurance company. It is completely a documentation game.
I should probably add that a lawyer is an absolute necessity in a workers compensation case. It is the lawyer’s support staff that is most important asset a long term workers compensation case. The paralegals assist in all the paperwork. It is a long drawn out process and nothing happens fast.
The original post, which seems like an eternity ago, is copied below.
Regards,
Charles King, C.P.
Ertl Issues
In approximately one week a friend and patient will be having an independent medical exam (IME) to determine if the workers compensation insurance company will authorize the Ertl procedure as recommended by her attending physician. This may ultimately end up in a hearing judged by a Commissioner of the Workers Compensation Commission (WCC). It is important to make sure that all the physicians who offer an opinion in this case are fully informed and hopefully agree.
This is an obscure operation in our state as only one physician does the procedure. The question I would like to ask the list is what documentation would you recommend bringing to the IME and possibly a WCC hearing, for a physician who most likely would not be familiar with the procedure?
Thank you,
Charles King, C.P.
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