The Independent Medical Examination (IME)

Introduction

This article is written for physicians interested in conducting Independent Medical Examinations (IMEs), with practical advice on preparation, examination, reporting, and legal interaction.

What is an IME?

An Independent Medical Examination (IME) is a usually one-time evaluation performed by an independent medical examiner who is not treating the claimant/examinee, to answer questions posed by the party requesting the IME. It is a specialized evaluation best performed by a physician who should have special training and experience in assessing issues unique to an IME. Although IME reports share some similarities with conventional medical reports, the IME is distinctly different. The report is not necessarily intended to facilitate the well-being of the examinee.

The term IME is somewhat of a misnomer. The evaluation is obtained by either the defense attorney or insurance company/claims examiner or by the plaintiff attorney, and while the evaluator is supposed to be independent and not show any bias, and while your goal should be to do an equal the number of defense and plaintiff cases, and provide impartial opinions based on the evidence, the reality is that many physicians do primarily defense or plaintiff work.

An IME includes the essential elements of a medical assessment, including a history, usually, but not always, a physical examination (sometimes only a records review was requested), and review of relevant records and applicable diagnostic studies, followed by clinical impressions or diagnoses and then by recommendations. The IME also discusses, depending on the request from the referral source, disability (definition is jurisdiction dependent) based on activity of daily living deficits; and claims issues which can include MMI (maximal medical improvement) status, causation, apportionment, impairment, work ability, prognosis, and the appropriateness of past medical costs, along with future medical care needs.

IME vs. Medical Consultation or Treatment

Unlike a medical consultation report, the IME report is not confidential and is likely to be read by many stakeholders in the claim; it should be easily read and understood by non-medical personnel. Standards for independent medical evaluations have been published.

While an independent medical evaluation has some similarities to a comprehensive medical consultation, there are significant differences. Medicine and law have different approaches. The practice of law is based on the advocacy system and is contentious and argumentative in nature by design. It is a system that allows different and conflicting points of view to be heard, with resolution achieved by way of a jury, a judge, or through arbitration. The practice of medicine is focused on diagnosing and treating patients to the best of the physician’s ability to help them regain and maintain good health.

Physicians providing either a one-time consultation or ongoing medical care are accustomed to having their advice sought and followed by a usually grateful patient. Whereas in the legal system, physicians can expect to have their opinions challenged vigorously and in detail by skilled opposing attorneys. In some cases, physicians may have their credentials and ability to testify as an expert questioned in a harsh and demeaning manner. While the attack may seem personal, in fact, it is only a method used by attorneys to discredit physicians' testimony to either have it thrown out or its value minimized. A skilled attorney will ask questions that are often difficult to answer, and physicians may find that the opportunity for explanation may be limited.

IME Referral Sources

IMEs are an integral part of case management and are utilized widely by insurers and attorneys in a variety of areas, including automobile casualty, workers’ compensation, personal injury, medical malpractice, and long-term disability. The term Civil or 3rd Party litigation is sometimes used to designate nonworkers’ compensation cases, such as automobile casualty and personal injury. It is important to understand that each of these systems/jurisdictions is unique, with different definitions of disability, while having different requirements for reporting.

Workers' compensation systems are no-fault, but litigation issues often center around causation, the extent and duration of medical care needs, the length of temporary disability, the extent and cost of permanent impairment and/or disability, and issues of apportionment to non-industrial causation. Civil or 3rd Party litigation, including malpractice cases, involves primarily the cause and extent of injuries and the level of associated disability, activity of daily living deficits, loss of work capacity, and future medical care costs. Once a lawsuit is filed, the defendant is generally allowed one IME. In these cases, the defendant is counting on the IME to be unusually thorough, as the case may hinge on the examination findings and report conclusions.

Short- and long-term disability cases range from private disability policies to Social Security benefits for persons expected to be totally disabled for at least 12 months, to individuals who have purchased or been provided by their employer private disability insurance policies. These cases focus on work ability with a contract-specific definition of disability.

IME Reporting

While the quality of the physician's testimony at a deposition, arbitration, or trial may be critical, the initial written report is typically most important. This report is relied upon in any settlement negotiation and often becomes part of the evidence. The well-written and defensible report must be valid, defensible, and readable. A well-written report will assist the IME physician during deposition cross-examination and may even discourage the opposing attorney from going to trial; thus, the report itself may lead to early case settlement or resolution. The physician will be judged by the quality of the written report. A poorly written report reflects negatively on the IME physician and may damage the underlying case. A well-written report enhances the reputation of the IME physician and leads to further referrals.

Best Practices for IME Work

Stay within your area of expertise. No good comes out of providing opinions outside the scope of your training and expertise. Do not be pressured by the referral source to change or modify a report to meet the “needs” of the client. It is critically important to have the referral source make it very clear what areas of opinion are being requested; for example, if causation is not at issue, there is no need to address it.

A quality IME report is responsive to the specific questions asked by the referral source. The report should be understandable by non-medical individuals. In some contexts, a verbal report is provided prior to submission of a written report, thus giving the referrer the opportunity to further direct specific questions or concerns or to even defer on receiving a written report. Whether the referral source is an insurance carrier, defense or plaintiff attorney, they are much better off with an honest opinion before wading further into the subject case.

Evaluation reports should include appropriate formatting, be free of spelling errors, and be grammatically correct. All material and records reviewed should be listed. Paragraphs should be kept relatively short and separate ideas should be put in distinct categories. Unnecessary repetition should be avoided. Use unambiguous language that can be easily understood by the referral source. When reporting, superfluous information should be left out. The claimant, as well as past treating and evaluating physicians, should not be disparaged. List the time spent with the claimant face-to-face. The report should contain all opinions to be expressed at a hearing or trial.

IME Fees

It is important to provide documentation regarding charges, and usually, a curriculum vitae will be requested. Some physicians insist on a pre-payment advance prior to reviewing records, providing an examination report, or attending a deposition, arbitration, or trial. Charges should include costs for late cancellations, records review, the actual examination, report writing, research, meeting time with the referral source, deposition, arbitration, and trial testimony time.

Preparing for the IME Encounter

It is appropriate to review records in advance to ensure that all historical items are reviewed with the examinee. Many physicians will prepare the medical record summary in advance and prepare a template for their report. This is very important, particularly for defense examinations where the IME physician will have only one chance to examine the claimant. There may be issues found in the medical records that need to be addressed.

If the evaluation is being accomplished at the request of the examinee's attorney, there is an implied understanding that the physician is serving in that individual's best interest. When examining for the defense (the other side), it is not uncommon to find an examinee who is, at a minimum, suspicious and maybe even hostile. For a defense IME, there may be limitations set ahead of time by the plaintiff attorney on what questions can be asked and what body parts can be examined. These issues should be discussed with the referring defense attorney prior to the examination. Depending on the jurisdiction, the claimant’s attorney or representative and sometimes even a court reporter or videographer may attend the evaluation.

It is important in any scenario to carefully explain your role, including the fact that no doctor-patient relationship is implied. The examinee is told not to perform any maneuver that her or she feels will be harmful to them. Adequate gown coverage is important, and a chaperone is recommended. Time spent face-to-face is listed, as well as noting any others present at the IME. Typically, the physician’s opinions and any recommendations are not discussed with the examinee unless specifically requested by the referral source.

The IME Report

Physicians are aware of the usual details covered in a standard history and physical examination. The IME report goes into much greater detail in certain areas. The examinee’s preinjury status is carefully detailed. It is very important to determine if there was any condition, impairment, or disability predating the injury. The history of injury, subsequent events, and medical care up to the present time are carefully ascertained. In addition to current symptoms and complaints, what are aggravating and alleviating factors? Note and comment on the appropriateness of the use of adaptive equipment, such as braces, canes, wheelchairs, etc., should be noted. A functional history should be obtained regarding activities of daily living. Obtain a description of the examinee's daily routine (exercise, outdoor activities, recreation, household chores, etc.) and changes from pre-injury status. If work capacity is an issue, it is also important to assess more complex issues such as pacing (speed of activity), repetition (repetitive activities), time (prolonged activity), and positioning (static or awkward posturing).

Any inconsistency between the individual’s report and information found in the medical record is noted. It is important to remember that medical records may be inaccurate or have left out important details, but also that the examinee may have selective memories and, sometimes, what they remember is not accurate. Any examinee's credibility issues should be discussed and explained.

The physical examination is not limited to but is directed to the concerned body parts, and when a change or abnormality is identified, the appropriate regional examination is expanded. While the physical examination is similar to a medical consultation, it is important to document negative, positive, and non-organic findings.

The examination integrates information obtained from physical findings to support or refute diagnoses suggested during the history taking. The examination may uncover physical findings not readily apparent from the history or even known to the examinee.

Based on the findings from the history, review of medical records and other documents, physical examination, and clinical studies, the evaluator responds to the specific questions asked by the referral source.

The IME physician cannot base opinions solely on the basis of education, training, and experience. Rather, the evaluator must provide a clear description of why a conclusion has been reached, including reference to the facts, current science, and best practices.

Opinions are stated clearly and explicitly using terminology such as “based on a reasonable degree of medical probability.” This means “more likely than not”, i.e., that there is a probability greater than 50%. All opinions should be supported with a detailed explanation to justify those opinions.

Provide a succinct summary of the history and physical examination, followed by opinions (when requested) on the specific issues requested by the client. The IME physician commonly provides a disclosure at the end of their reports, such as:

The opinions and conclusions in this report are based upon a reasonable degree of medical probability. I reserve the right to change any opinion expressed upon production of additional medical records or new information.

NB: Certain jurisdictions may require other disclosures.

Gaining and Maintaining IME Referrals

Your reputation, responsiveness, availability, report quality, impartiality, communication skills, and recognized expertise are critical in gaining and maintaining IME referrals. Here are a few thoughts and suggestions:

• Are you prepared to:
  
  • Have your opinions questioned/challenged by the opposing attorney?
    
  • Be responsive and available to your referral source, including on nights, weekends, and on vacations?
    
  • Change your work schedule repeatedly to testify at trial?
    
• Do you have the bandwidth, time, and inclination to do the following:
  
  • Have quality staff and efficient systems in place to quickly and expertly respond to referral sources.
    
  • Develop and maintain a database of potential referral sources.
    
  • Write a monthly educational newsletter.
    
  • Network with your colleagues and referral sources at educational and scientific meetings.
    
  • Pursue and engage in speaking engagements at referral source offices and at professional meetings.

Conclusion & Some Further Thoughts

Doing IME work is intellectually stimulating and financially rewarding, but it is not for everyone. You may be an excellent treating or consulting physician and diagnostician, but that does not mean that you are cut out to do medical-legal evaluations. If you are interested in pursuing IME work, I suggest you discuss this with your colleagues who already do IMEs, research the topic, and take courses. There are IME medical management companies that you may choose to align with, which provide support, training, and education.

There are also a number of companies and organizations that specialize in IME education and membership.

• SEAK Link
  
• American Medical Association (AMA) Link
  
• eMedicoLegal Link
  
• American Board of Independent Medical Examiners (ABIME) Link
  
• International Academy of Independent Medical Evaluators (IAIME) Link

REFERENCES

1. Babitsky S, Mangraviti JJ, Melhorn JM. Writing and Defending Your IME Report: The Comprehensive Guides. Falmouth, MA: SEAK; 2004. Link
   
2. Brigham CR (ed.) AMA Guides Newsletter. Bi-monthly. Chicago: American Medical Association. Link
   
3. Brigham CR, Mangraviti J, Babitsky S. Independent Medical Evaluation Report: A Step by Step Guide with Models. Falmouth, Mass: SEAK; 1997. Link
   
4. Demeter SL, Andersson GBJ. Disability Evaluation, Second Edition. Chicago: American Medical Association; 2003. Link
   
5. Gerhardt J, Cocchiarella L, Lea R. Practical Guide to Range of Motion Assessment. Chicago: American Medical Association; 2002. Link
   
6. Kertay L, Eskay-Auerbach M, Hyman M. AMA Guides to Navigating Disability Benefit Systems. Chicago: American Medical Association; 2016. Link
   
7. Mayer TG, Gatchel RJ, Polatin PB, eds. Occupational Musculoskeletal Disorders: Function, Outcomes & Evidence. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2001. Link
   
8. Melhorn M, Talmage JB, Ackerman WE, Hyman NH. Guides to the Evaluation of Disease and Injury Causation, Second Edition. Chicago: American Medical Association; 2014. Link
   
9. Rondinelli RD, Guides to the Evaluation of Permanent Impairment, Sixth Edition. Chicago: American Medical Association; 2008. Link
   
10. Rondinelli RD, Katz RT. Impairment Rating and Disability Evaluation. Philadelphia, Pa: WB Saunders; 2000. Link
    
11. Talmage JB, Melhorn JM, Hyman MH. Guides to the Evaluation of Work Ability and Return to Work, Second Edition. Chicago: American Medical Association; 2011. Link
    
12. Feinberg, S., and Brigham, C. The Independent Medical Examination (IME) Handbook. Link
    
13. Medical Impairment, Disability Evaluation and Associated Medical Legal Issues. Edited by Robert D. Rondinelli, Marjorie Eskay-Auerbach. Physical Medicine and Rehabilitation Clinics of North America, Volume 30, Issue 3, August 2019. Link
    
14. Ranavaya, Mohammed I. Physician's Guide to Medicolegal Practice. Chicago, Illinois: American Medical Association, 2019. ISBN: 978-1-62202-800-9. Link
    
15. SEAK, Inc. (2025) – How to Perform an Independent Medical Examination. Practical guide including latest tips on IMEs, report writing, and defending your opinions. Link
    
16. AAOS Now (May 2025) – Tips and Guidance for Starting an Independent Medical Examination. Recent best practices for IME processes, reporting, and avoiding legal pitfalls (for orthopedic surgeons, broadly applicable). Link
    
17. American Medical Association (2024) – Report of the Board of Trustees 32-A-24: Independent Medical Evaluation. Official consensus statement on IME standards and recommendations. Link
    
18. Washington State Dept. of Labor & Industries (2022–2025) – Medical Examiners' Handbook. Guidelines and templates for IME and impairment ratings, including billing and process protocols. Link
    
19. Debofsky Law (2024) – What to Expect at an Independent Medical Examination (IME). Public-facing article explaining IME preparation, common examiner issues, and optimal practices for experts. Link
    
20. ScienceDirect (2024) – Conceptualising the quality experience for independent medical examinations. Latest review of IME quality principles and reporting standards. Link