Page 12 - GP Spring 2019

How to Approach a Dental Independent Medical Exam

By Joseph DiDonato, III, DDS, MBA, FAGD
The dental independent medical exam While doing an IME may appear to be a in determining the company’s liability.
(IME) is used by third parties to discover matter of examining the claimant and The cause is defined as the association of
the condition of individuals who have making a determination, having a plan one event with another. It is the particular
made insurance claims, had been involved and fully understanding the particulars aspect of an event bringing on the start of a
in an accident, worker’s compensation, of the case can improve your efficiency new phenomenon. A pre-existing condition
or malpractice. It is an opportunity for in arriving at an opinion (Table 1). I start can be viewed very differently than a new
a third party to have a dentist provide by reviewing the questions from the third event.
expertise in reviewing records, treatment party and then review the chart with the
outcomes and the veracity of those who intent to discover where the records can IME examiners are tasked to report what
claim to be injured. The IME can be used to answer the questions. My reports take on they learn during an IME to the third party.
investigate a broad spectrum of sometimes the form of first reviewing the incident that As an examiner if you can recognize an
controversial topics especially when it caused the loss, then I list all the records I aspect of science that can shed light on
involves a legal challenge. have been asked to review. Then I highlight the given case and you can properly make
my remarks about the inadequacies found a case for it, you should include it in your
This article will consider cases where third in the records, particularly if radiographs report. Your task is to observe and report
parties desire a professional opinion after are missing or non-diagnostic. I ask the what you can determine.
an accident, which are typically motor company providing the IME logistics to
vehicle or work related. I will discuss how see if they can remedy the problem with the It is important to be sure that the event is
I approach cases and use some examples radiographs. Often it is an oversight and indeed what caused the loss. Many people
where TMJ and soft tissue injuries present better diagnostic radiographs are found. are walking around with dental problems
diagnostic challenges. Lastly, I will Many times the records are out of order and or clicking joints and would be willing to
discuss how I codify the IME and score need to be collated. Record administration make an insurance claim in order to acquire
claimant responses to look for instances of is important since it speeds your treatment or financial gain. Remember the
inconsistencies between the medical record understanding of the timeline in the case decision on paying the claim in not up to
and a claimant’s response, and how these and helps to prevent a misinterpretation you, that is for the insurance company to
findings can shape an IME opinion. based on a faulty order in the records. In decide. They charge you with determining
order to do IME’s in a timely manner it the facts about the case as it relates to the
When first asked to do an IME you should is essential to manage the records, the dental condition.
be careful to evaluate your expertise in the exam and the production of a report in an
area of interest. In some cases the answer efficient manner. Grasping the essential Consider this, at the time of an injury the
could be simple and well within the domain information contained within hundreds claimant had advanced periodontal disease
of a general practitioner. For example, of pages of medical and dental records and had been unaware of the condition.
a patron claims to have broken a tooth (some handwritten) requires sorting During an MVA the claimant bites down
at a restaurant and files a claim with the information on the first pass, and making hard and dislodges a tooth adjacent to an
management. The patron presented to their sure to highlight what is considered to be edentulous space. Was the loss of the tooth
dentist with a broken tooth and a crown important in the eyes of the examiner. caused by the accident? Is there a pre-
was recommended. Now the claimant existing condition that can be identified?
is petitioning for reimbursement. The Having a plan for each case type is beneficial.
claimant’s dentist has attested that the tooth For example, in the case of fractured or The finding was that this was not a sound,
was fractured. Should be easy to determine. lost teeth in an motor vehicle accident healthy tooth. Remember the job of the IME
Right? (MVA), I gather as much information from investigator is not to determine liability.
the claimant about how the event caused The task is to interpret the dental history,
However, the forty plus pages of records the loss. I then compare the mechanism make a diagnosis and make an informed
show that the tooth was decayed, had a large of the injury with the evidence presented. opinion on the cause of the condition.
restoration and the claimant was advised to In doing so, I sometimes find interesting
have a crown years ago. Now what? Well, anomalies, such as a claimant, who while What to look for in a case: a pattern of
without considering all the messy details sitting in the front passenger seat fractured submission
that could be dreamed up, we could simply the incisal edges of tooth #10 on the right Often claims present in one of the
provide a statement of what we do know, side window during a minor MVA with no following patterns: poor written records,
which is that the tooth was not a sound, airbag deployment- not just once, but twice time discrepancy, or an inconclusive
natural tooth, but was compromised by within a few years. Clearly the timeline and dental treatment record. For example,
secondary caries. The decision of whether the similar cause of the injury for these two this is a pattern I have seen especially
to indemnify the claim is in the domain of events might raise an eyebrow. How did when periodontal disease is a pre-existing
the insurance company, but the expertise to this injury occur? How did the claimant’s condition. The claimant states the tooth
understand the facts of the case is within the head come to be turned in such way as to was ‘knocked loose’ at work and they want
domain of the general practitioner. It is a strike the window- twice? an implant. Hallmarks are no supporting
required ability to diagnose decay, read and information from a treating dentist on the
interpret a dental record and understand the Often third parties are interested in prior dental condition (x-rays are usually
treatment protocols for a fractured tooth. determining the cause of an injury non-diagnostic), there is a delay in seeking
And another claim against the restaurant is and whether there are any pre-existing treatment (sometimes one to two months)
dismissed. conditions. These are important components and the attending dentist statement reports
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