Policy Statement  Policy Regarding Board Review of Record Reviews by IMEs

Date:	12/06/2017
Referenced Sources:	Statutes and Regulations (Allied Health)

Policy Regarding Board Review of Record Reviews by IMEs

The primary purpose of the Board of Registration of Allied Health Professionals (“Board”) is to assure the protection of the citizens of the Commonwealth of Massachusetts by overseeing the licensure and standards of practice set forth in the statutes, regulations, and rules for the professions of Athletic Training, Physical Therapy and Occupational Therapy.

One means by which the Board does this is to review complaints submitted to the Board regarding possible violations of the statutes, regulations, and rules set forth by the Board.  The Members of the Board review and discuss all documentation relative to the complaint to determine if the objective facts, as presented to the board by the complainant, by the licensee's response, and by the board's investigation, meet the level of a disciplinary violation.  Information critical to the board being able to perform its function is objective information regarding care rendered, the supervision of support personnel and information regarding any type of fraudulent activity. In completing one of the primary duties of the Board, protection of the public, the Board weighs the information submitted in the complaint regarding patients’ exposure to harm or potential harm resulting from the care rendered by a provider. 

Frequently complaints are submitted to the Board by third party payers after record reviews completed by independent examiners hired by the payer.  In these cases, the Board perceives that third party payers are asking the Board to render decisions as a means of substantiating the reimbursement value of the treatment rather than protecting the public from harm or potential harm.  Often times the third party payer is relying upon the subjective opinion of outside record reviewers regarding the quality, standard or substandard level of care delivered to a patient.   The results of our survey of the last 25 months of Board review of investigations reveals that, of 57 complaints involving IMEs, 29 were dismissed by the board, or a 51% dismissal rate.  The Board has observed that what is occurring, for more than half of complaints submitted by third-party payers, is that those facts are not supporting disciplinary violations, be they for:

1. fraud affecting consumers, not subjective characterizations of overutilization with no further supporting documentary or evaluative disciplinary violations, 
2. failure adequately to supervise supportive personnel as demonstrated by an objectively verifiable violation of 259 Code Mass. Regs. § 5.02(2), (3); or
3. negligent practice resulting in consumer harm.

As stated previously objective information regarding care rendered, supervision of support personnel and evidence of fraudulent activity, rather than the subjective “opinion of the reviewer” would be valued and welcomed by the Board.  Since the Board’s membership is comprised of volunteer-professionals who meet in open meeting only once a month, it would be greatly appreciated if a critical eye were cast on future submissions to the Board by way of complaints, to ensure that these standards are objectively and verifiably met.

 

Revised February 28, 2013