Medical Exams (IME) and Physician File Reviews (PFR)
4121.43; R.C. 4123.511; R.C. 4123.53; R.C. 4123.56; R.C. 4123.57(A); R.C.
4123.651; R.C. 4123.68; OAC 4121-3-12; OAC 4121-3-15; OAC 4123-3-09; OAC
4123-3-15; OAC 4123-3-16; OAC 4123-3-32; OAC 4123-6-40; OAC
4123-15-03; IC Resolutions R03-1-02, R03-1-04, R96-1-01, and R15-1-01
R. Abrams, Chief Operating Officer
Management policies, directives and memos regarding independent medical exams
and physician file reviews that predate the effective date of this policy.
09/29/17, New 02/04/16
purpose of this policy is to ensure that BWC or a managed care organization
(MCO) obtains independent medical exams (IMEs) or physician file reviews (PFRs)
when required by statute or when needed to support the claims management process.
policy applies to BWC claims staff and MCO staff.
of Substantial Aggravation: A determination that a condition that was allowed for the
substantial aggravation of a pre-existing condition has reached a state such as
would have existed had the injury not occurred; and, therefore, compensation
based on and medical treatment for the condition is no longer payable.
A business that contracts with individual disability evaluator physicians to
perform administrative aspects of an exam or file review, such as scheduling
appointments, preparing reports and billing.
Dispute Resolution (ADR) Exam: An exam conducted as part of processing a
medical dispute between an employer of record (EOR), an injured worker (IW), a
provider and/or an MCO arising from the MCO’s decision regarding a medical
treatment reimbursement request. An IW or EOR shall exhaust the ADR process
prior to filing an appeal pursuant to R.C. 4123.511 regarding an MCO’s decision
on a medical treatment reimbursement request.
Evaluators Panel (DEP): A panel of physicians contracted by BWC to perform IMEs
and PFRs. The panel was established to provide quality, impartial IMEs and
PFRs. Physicians must provide objective, accurate IMEs and PFRs that produce
concise, timely and justifiable reports.
Unforeseen Circumstances: Based on Ohio Industrial Commission (IC) Resolution
R03-1-04, extraordinary unforeseen circumstances include, but are not limited
of an immediate family member;
or medical emergencies;
of the exam was not received due to an incorrect address;
notice of the exam was not provided to the injured worker; or
of Disability (EOD): An evaluation of IW’s allowed condition(s) in the claim regarding:
IW’s ability to return to the former position of employment;
which prevent the IW’s return to the former position of employment;
IW having reached maximum medical improvement (MMI);
feasibility of a referral for vocational rehabilitation services; and
IW’s eligibility for continued temporary total compensation (TT).
IME that takes place in Ohio or in a bordering state within a 50-mile radius
from the Ohio state border.
Medical Exam (IME): An
impartial evaluation conducted at the request of BWC by a qualified medical
specialist that results in an objective evaluation and a comprehensive report that
is used in managing the claim for appropriate medical care, disability status and/or
payment of compensation.
Maximum Medical Improvement (MMI): A treatment plateau
(static or well-stabilized) at which no fundamental functional, physiological or psychological change can be expected
within reasonable medical probability in spite of continuing medical or
rehabilitative procedures. An injured worker may need supportive treatment to
maintain this level of function.
Disease (OD): A
disease contracted in the course of employment, which by its causes and the
characteristics of its manifestation or the condition of the employment results
in a hazard which distinguishes the employment in character from employment
generally, and the employment creates a risk of contracting the disease in
greater degree and in a different manner from the public in general.
Disability Guidelines (ODG): A comprehensive international medical treatment
and return to work guideline that provides evidence-based decision support to
improve, as well as benchmark, outcomes in workers' compensation claims.
An IME that takes place outside of a 50-mile radius from the Ohio state border.
to a Claim: IW,
IW representative, employer, employer representative and BWC.
of Permanent Partial (%PP) Compensation: Also referred to as a %PP and/or C-92 award. Compensation awarded
for residual impairment, either physical or psychological, resulting from an
allowed injury or occupational disease (OD) in state fund or self insured (SI)
File Review (PFR):
A DEP physician’s review of the medical documentation in an IW’s file that
results in a report BWC uses to assist with claims management.
Loss Compensation (SL): An award pursuant to R.C. 4123.57(B) made to an IW for the
amputation of, or loss of use of, a body part or a facial disfigurement.
Occupational Disease: For purposes of this policy, a disease that is considered
to be an OD and compensable as such when contracted by an employee in the
course of the employment in which such employee was engaged and due to the
nature of any process described in R.C. 4123.68 and for which an exam must be
scheduled prior to determination of a claim.
Total Compensation (TT): Compensation paid to an IW who is unable to return to the
former position of employment on a temporary basis due to the work-related
injury or OD, and who has not been found to have reached MMI.
IV. GENERAL POLICY FOR INDEPENDENT MEDICAL
EXAMS (IME) AND PHYSICIAN FILE REVIEWS (PFR)
It is the policy of BWC to consider when selecting a DEP physician that
the medical specialty of the selected physician must be appropriate for the
allowed conditions in the claim and/or the issue presented for consideration.
The DEP physician selected must have neither a conflict of interest nor
the appearance of a conflict of interest. Possible conflicts of interest
include, but are not limited to, when the DEP physician:
Is in the IW’s immediate family;
Works with a member of the IW’s immediate family in the DEP physician’s
practice or clinic;
Is in the immediate family of the IW’s treating physician/physician of
record in the current claim;
Previously provided treatment to the IW as part of the current or
another workers’ compensation claim;
Performed an IME of the IW as part of the current or
another workers’ compensation claim for BWC, the IC, the EOR or the IW in the
last 36 months;
Completed a PFR of the IW’s current or another workers’ compensation
claim within the last 12 months for BWC, the IW or the EOR;
Is in the same practice or clinic with a provider described in 4, 5 or 6
Has a personal, professional, or contractual relationship with the MCO
assigned to the current claim (however, merely being on an MCO’s provider panel
or network as a treating physician does not in and of itself disqualify a DEP physician
from performing IMEs or PFRs on IWs assigned to the MCO);
Has a personal, professional or contractual relationship with the IW,
the EOR, or their representatives;
the medical director for the MCO managing the current claim, or is a member of
the same practice or clinic with the medical director for the MCO managing the
current claim; or
5% or greater financial interest in the MCO managing the current claim.
BWC will attempt to avoid a conflict of interest when selecting a DEP
physician, the DEP physician must, as a condition of the DEP agreement,
identify any conflict of interest and withdraw from completing an IME or PFR
when one exists or appears to exist.
is the policy of BWC to require that the DEP physician:
Include in a narrative report an opinion based on the allowed conditions
with references to the medical relied upon; and
Include answers to all questions with supporting rationale.
It is the policy of BWC to refer all concerns or complaints regarding a DEP
physician to BWC’s DEP Central unit.
It is the policy of BWC that IME and PFR reports and addendums be imaged
into the claim immediately upon receipt.
The original report must be imaged without waiting for an addendum
should one be needed.
See Section V.K. below for additional information regarding addendums.
V. POLICY FOR INDEPENDENT MEDICAL EXAMS
It is the policy of BWC to schedule IMEs as required by law or when the
need is identified in the course of claims management, and require that an IW
appear for BWC scheduled exams.
It is the policy of BWC to provide the IW and examining DEP physician notice
at least 14 days in advance of the exam date whenever possible.
Notice to the IW and DEP physician is provided in writing.
If the exam must be scheduled with less than 14 days notice, BWC shall also
call the IW to provide notice of the exam.
BWC shall select the physician to conduct an in-state exam. In-state
exams are scheduled:
Directly with the examining physician; or
Through an administrative agent when the DEP physician selected by BWC
has notified BWC that they use an administrative agent.
Out-of-state exams are scheduled through an administrative agent.
is the policy of BWC to consider the geographic proximity between the IW’s
residence and IME location.
The IME will be scheduled at the acceptable location that is closest to
the IW’s home, taking into consideration available times, specialty of
physician needed and possible conflicts of interest.
The IW shall be reimbursed for expenses when attending an exam that requires
travel outside of the IW’s permanent or temporary residence.
Mileage is reimbursed for travel over 45 miles round trip.
See the Travel Reimbursement policy for additional information
regarding requirements for travel reimbursement.
is the policy of BWC that the IW must provide photo identification at the time
of an exam.
It is the policy of BWC to prohibit IW representatives, EORs, EOR
representatives or MCO representatives from being present during an IME.
The IW may have a relative or chaperone present during an exam.
An interpreter may be present for an exam. See the Interpreter
Services policy for additional information.
It is the policy of BWC to prohibit the IME or PFR physician from
communicating with the parties to a claim or their representatives regarding
the examination or report.
is the policy of BWC to prohibit audio or video recordings in the exam room.
is the policy of BWC to image all IME and PFR reports to the electronic file
for review online by the parties to a claim. For C-92 reports, a copy of the
report shall be mailed either separately or with the BWC Order. BWC will
provide a hard-copy of all other IME reports, file reviews and any addendums
When an IW fails to appear for an IME, it is the policy of BWC to
evaluate if the reason the IW failed to appear was for good cause based on extraordinary
unforeseen circumstances. See L through S of this section below for failure to
appear information for each type of exam.
It is the policy of BWC that IME reports:
Be submitted within 10 calendar days of the exam, except in the case of
an ADR exam;
Be submitted within 5 calendar of the exam in the case of an ADR exam;
Not be altered in any way, such as cross outs or white outs (see the Standard
Claim File Documentation policy for further guidance on altered documents);
Be dated and contain the DEP physician’s signature; and
Contain the IW’s name and claim number on each page of the report.
It is the policy of BWC that only BWC or the MCO may request an addendum
to a DEP physician’s report and that such request be made in writing.
The initial request may be made by telephone, but must be followed up
with a written request.
The request for an addendum must be copied to all parties to the claim.
The original report must be imaged in the claim without waiting for the
The addendum must be imaged in the claim upon receipt.
It is the policy of BWC to schedule exams prior to making the initial
decision in a claim as required by statute or when BWC identifies the need for
Is required before determining an OD claim for these conditions:
iv. Coal miner’s pneumoconiosis;
v. Cardiovascular or pulmonary disease for
firefighters or police officers; or
vi. Any other OD of the respiratory tract
resulting from injurious exposure to dust.
May be scheduled, depending on the situation, for:
i. Other ODs;
ii. Forced sexual conduct; or
iii. Other initial determinations as identified
It is the policy of BWC to require the minimum evidence as described in IC
Resolution R15-1-01 “Modification of R96-1-01 and R03-1-02 related to
medical evidence necessary to support a claim for an asbestos-related condition”
for the following types of diseases:
Coal miners’ pneumoconiosis; or
Any other occupational disease of the respiratory tract resulting from
injurious exposure to dust
Failure to appear for an exam regarding the initial determination of a
claim for reasons other than good cause may result in denial of the claim.
See the Initial Claim Determination and Occupational Disease
Claims policies for additional information.
is the policy of BWC to schedule EOD exams as required by statute or when BWC identifies
the need for an exam.
BWC shall schedule an EOD IME no later than 30 days after the first 90-consecutive-day
period for which the IW is paid TT compensation, unless waived by the employer
The employer may waive the 90-day exam, either permanently or
If the waiver is temporary, a date must be given for when the exam
should be considered again.
The waiver may be in writing, using a Waiver of Examination
(MEDCO-6) or equivalent form.
If the employer is out of business or fails to respond to BWC’s request
to waive the exam, BWC may waive the exam.
If the employer objects to waiving the exam, BWC shall schedule the
Reasons to consider waiver of the exam include, but are not limited to:
i. Surgery is scheduled or was recently
ii. Type of surgery and mode of anesthesia;
iii. Normal recovery time for surgery based
iv. Post operative passive physical therapy
is being performed;
v. The IW remains hospitalized for the
vi. Referral for or active participation in
a vocational rehabilitation plan is underway;
vii. The disability management coordinator
(DMC) provides a recommendation regarding the IW’s potential success or compliance
with vocational rehabilitation plan services;
viii. Projected discharge date from inpatient hospitalization and
normal healing times recommended in the ODG;
ix. Notes from the physician of record (POR)
or treating physician documenting IW’s progress in a treatment plan; or
x. Other medical factors that justify waiving
BWC shall schedule an EOD IME immediately after the IW has received 200
weeks of TT compensation.
BWC may schedule an EOD IME anytime:
When TT is on-going; or
When a request for a new period of TT has been received.
The IW must be receiving or have requested TT on the date the exam is
If the IW returns to work prior to the exam taking place, BWC shall
cancel the exam.
Failure to appear for an EOD IME for reasons other than good cause may
result in suspension of TT.
See the Temporary Total Compensation policy for additional
Loss: It is the policy of BWC to schedule an exam regarding requests for SL
when BWC identifies the need for an exam.
Failure to appear for an exam regarding SL may result in the suspension
of the request for SL.
See the Scheduled Loss Compensation policy for more information.
Dispute Resolution (ADR)
Failure to appear for an ADR exam for reasons other than good cause may
result in the suspension of medical treatment in the claim.
ADR exams may be completed by a BWC-certified physician who is not on
See the Alternative Dispute Resolution Exams policy for
Initial Determination of %PP or an Increase in %PP: It is the policy of
BWC to schedule exams for the initial determination of %PP as required by
statute or for an increase in %PP when BWC identifies the need for an exam.
The DEP physician selected is not required to maintain an active
practice but must have additional training in the %PP process.
The DEP physician must use the version of the “American Medical
Association’s Guide to the Evaluation of Permanent Impairment” (AMA Guides) approved
Failure to respond to BWC’s attempt to schedule or failure to appear for
a %PP exam without notice or explanation may result in dismissal of the C-92
See the Percentage of Permanent Partial Disability or Increase of
Permanent Partial Disability Compensation policy for additional
Conditions: It is the policy of BWC to schedule an exam for the determination
of additional conditions when BWC identifies the need for an exam.
Failure to appear for an additional allowance exam for reasons other
than for good cause may result in suspension of the request for the additional
See the Additional Allowance policy for additional information.
of Substantial Aggravation: It is the policy of BWC to schedule an exam to
evaluate the status of a condition allowed for substantial aggravation of a
pre-existing condition to determine if the condition continues to be payable when
BWC identifies the need for an exam.
Failure to appear for a scheduled exam to
evaluate a condition allowed for substantial aggravation of a pre-existing
condition for reasons other than for good cause may result in suspension of the
compensation or treatment requested based on that condition.
See the Aggravation and Substantial Aggravation of a Pre-Existing
Condition policy for additional information.
Claim Reactivation: It is the policy of BWC to schedule an exam
regarding the reactivation of a claim when BWC identifies the need for an exam.
Failure to appear for an exam scheduled regarding the reactivation of a
claim for reasons other than good cause may result in a suspension of the
request for reactivation.
See the Claim Reactivation policy for additional information.
It is the policy of BWC to conduct an investigation if an IW refuses to
submit to or otherwise obstructs an exam after appearing for the exam.
If it is determined that the refusal to submit or obstruction was
justified, the exam will be rescheduled and processing will continue.
If it is determined that the refusal to submit or obstruction was not
justified, processing will continue as if the IW failed to appear for the
is the policy of BWC to lift a suspension as the result of failure to appear
for a BWC-scheduled exam when:
The IW appears for a rescheduled exam; or
The issue that resulted in the BWC-scheduled exam is moot.
Employer-scheduled Exams in SF Claims
The EOR in a SF claim may schedule an IW for an exam by a physician of
the EOR’s choice one time on any issue asserted by the IW or the POR/treating
The EOR is responsible for the cost of the employer-scheduled exam.
The EOR shall provide the IW with a proper form to be completed by the
IW for reimbursement of expenses, including travel, related to attending an
employer-scheduled exam and shall pay the IW for such expenses immediately upon
receipt of the completed form.
If the IW is employed, the EOR shall pay the IW for any loss of wages
arising from attending the exam within three weeks of the exam date.
The employer shall inform BWC, the IW and the IW’s representative as to
the time and place of the exam, the questions asked of the examining physician
and the information provided to the examining physician.
Treatment by a company doctor constitutes an employer-scheduled exam.
If, without good cause, the IW refuses to submit to an exam scheduled by
the EOR or refuses to release or execute a release for any medical information,
record or report required to address an issue related to the IW’s claim, the
EOR may file a Motion (C-86) requesting the IW’s claim be suspended.
BWC shall refer requests to suspend a claim filed by the EOR to the IC.
See the Industrial Commission Suspensions policy for additional
If, after one employer-scheduled exam, the EOR asserts that another exam
by a physician of the employer’s choice for the same issue is essential in the defense
of the claim, the EOR may file a written request with BWC to require that the
IW attend another exam.
If the claim is pending before the IC and the question(s) sought to be
clarified by such an exam is not within the jurisdiction of BWC (e.g., Permanent
Total Disability [PTD] or a contested issue), BWC shall refer the request to
the IC for further consideration.
If the question sought to be clarified is within BWC’s jurisdiction
(e.g., allowance of an additional condition not under appeal to the IC), BWC
shall act immediately upon the request.
i. BWC may determine that the request
should be denied if the IW was recently examined by a doctor chosen by the
employer or for other reasons.
In cases of TT, a medical exam performed in the past 30 days shall be
regarded as recent.
In cases of additional allowances, a medical exam performed in the past
60 to 90 days may be regarded as recent.
ii. BWC shall:
Issue an order granting the request for an additional exam to be scheduled
by the EOR; or,
Refer the request to the IC if BWC’s decision is that the request should
The EOR shall arrange for an exam within 15 days from the receipt of the
order approving the exam and the exam shall take place not later than 30 days
from the receipt of the approval.
EOR shall file the doctor’s report with BWC immediately upon its receipt.
BWC shall consider written requests from the EOR for BWC to schedule an
BWC shall schedule an exam if BWC determines it is pertinent to the
management of the claim and BWC has jurisdiction to make the decision related
to the request; or
BWC shall refer a request for an exam to the IC if it is related to
issues outside of BWC’s jurisdiction or when BWC does not agree with the
BWC may, at the request of a SI employer, schedule an exam with a BWC DEP
physician on behalf of the SI employer.
The SI employer shall pay the provider for the exam.
The SI employer shall pay expenses and lost wages to the IW for such an
VI. POLICY FOR PHYSICIAN FILE REVIEWS (PFR)
It is the policy of BWC to obtain a PFR when necessary in the course of
claims management. Reasons a PFR may be obtained include, but are not limited
Identification of the proper diagnosis for the initial determination of
Determination of requests for the allowance of additional conditions;
Evaluation of requests for claim reactivation, including appropriateness
of medical treatment;
Processing requests for an increase in %PP;
Determining the IW’s eligibility for a SL award;
Determining if drugs requested or currently being reimbursed by BWC are
reasonably related or medically necessary and appropriate for the treatment of
allowed conditions in a claim; and
Determination of a claim or an issue in a claim when an exam is not
possible due to physical limitations that prevent an IW from being examined or
the IW has died.
It is the policy of BWC to require DEP physicians who complete PFRs to expressly
accept all findings of the POR/treating physician(s), but not necessarily their
opinion about those findings.
is the policy of BWC to provide copies of file review reports to parties to the
claim when requested.
BWC staff may refer to
the corresponding procedure for this policy entitled “Independent Medical Exams
(IME) and Physician File Reviews (PFR)” for further guidance.