“Orthopedics” May Not Be Specific Enough for Your Next IME

When a musculoskeletal claim requires an orthopedic IME, choosing the specialty may seem like the straightforward part. Choosing the right orthopedic physician can require considerably more thought.

But “orthopedics” can be only the beginning of the physician-selection process.

Consider two referrals: one involves a shoulder injury following a workplace incident, with questions about ongoing symptoms and treatment. The other involves a lumbar spine claim with prior degeneration, multiple interventions, persistent symptoms, and questions involving causation, maximum medical improvement and permanent impairment.

Both may appropriately call for an orthopedic surgeon. But that does not necessarily mean the same orthopedic physician is the best fit for both evaluations.

For claims professionals and attorneys, that distinction can matter. An effective physician match should account for not only the specialty printed on a physician’s CV, but also the clinical issues involved and, importantly, the medical questions the physician is being asked to answer.

Orthopedic Expertise Is Not One-Size-Fits-All

Orthopedic surgery encompasses a wide range of musculoskeletal conditions and areas of clinical focus.

The American Board of Orthopaedic Surgery (ABOS), for example, offers subspecialty certification in Surgery of the Hand and Orthopaedic Sports Medicine. Those certificates recognize qualifications beyond general orthopedic certification through additional training and a practice characterized by experience within those areas.

That distinction illustrates a broader consideration for an IME: two board-certified orthopedic surgeons can both be well qualified while bringing different experience to a particular case.

A physician whose practice has concentrated heavily on shoulders and knees may bring a different clinical perspective to a shoulder claim than a physician whose work has centered on complex spinal conditions. Likewise, a hand or upper-extremity case may warrant consideration of experience specific to those structures.

This does not mean every referral requires a formally subspecialty-certified physician. It means physician selection benefits from looking beyond the specialty label.

The Medical Question Matters, Too

Anatomy is only one part of the match.

Take the same shoulder claim and change the referral question.

One request may ask whether proposed additional treatment is reasonable and medically necessary. Another may ask whether current findings are causally related to the reported injury. A third may come after treatment has concluded and ask the physician to address maximum medical improvement and permanent impairment.

The body part has not changed. The purpose of the evaluation has.

That distinction becomes particularly important when impairment is involved. The American Medical Association’s Guides to the Evaluation of Permanent Impairment provides specific methodologies for musculoskeletal impairment, including separate content addressing the upper limb, lower limb, and spine and pelvis. The AMA also emphasizes that physicians performing impairment evaluations should consider which edition and requirements apply within the relevant jurisdiction.

For the party requesting the evaluation, this creates another useful question when selecting an expert:

Does this physician’s experience align not only with the condition being evaluated, but also with the opinion being requested?

A Shoulder Case and a Complex Spine Case May Need Different Things

Imagine that the shoulder claim involves a discrete injury, surgery and a relatively contained treatment history. The central questions concern current findings, additional treatment and work restrictions.

Now compare that with a lumbar claim involving years of pre-existing degenerative findings, a reported work injury, subsequent treatment, injections or surgery, and continued symptoms. The referral asks the evaluator to distinguish pre-existing pathology from the effects of the reported injury and address current treatment, MMI and impairment.

Calling both cases “orthopedic IMEs” is accurate—but it does little to describe the expertise each case actually requires.

The second case may place considerably more emphasis on longitudinal record review, imaging history, prior pathology and the relationship between those findings and the reported event. The first may present an entirely different clinical question.

This is why matching should begin before the appointment is placed on a calendar.

Start With the Question, Then Find the Expert

When Merit Medical Evaluations receives an orthopedic referral, understanding the case helps us determine which physician on our panel may be an appropriate fit. The injury, body region, treatment history, requested opinions, physician experience and practical requirements of the evaluation can all inform that decision.

Once that match is made, there are still details to manage: obtaining and organizing records, coordinating scheduling, communicating the referral questions, providing materials to the physician and moving the evaluation through report delivery.

Those administrative steps matter. But they support a more fundamental objective:

Getting the right medical question in front of the right medical expertise.

So the next time a case calls for an orthopedic IME, “Which orthopedic physician is available?” may not be the first question worth asking.

A better starting point may be:

“What specifically do we need this orthopedic expert to evaluate?”