Workers in California who are injured on the job and seek workers’ compensation benefits should understand the importance of an Independent Medical Review, also known as an “IMR.” This was discussed in a previous post. Knowing about IMRs extends beyond when and why it will be used. Those who have suffered a workplace injury and have concerns about workers’ compensation claims being denied should also be aware of the statistics for IMRs. The latest information shows that IMRs to resolve medical disputes in workers’ compensation cases reduced for the first time since the process was initiated. However, the results of the IMRs were steady, with more than 91 percent of the cases upheld.
The analysis comes from the California Workers’ Compensation Institute, in which 648,450 decision notifications were reviewed between 2014 and 2017 after there was a Utilization Review and the physician modified or denied a medical service that was requested. The goal of IMRs was to reduce the number of disputes about workers’ compensation and medical treatment. In 2017, there was a reduction of 3,808 from 2016, a decline of 2.2 percent. In 2017, the UR decisions were upheld at the same rate as 2014 to 2016.
Reviews stem from injured workers asking for prescription medications, anti-inflammatory drugs, musculoskeletal drugs and dermatological drugs, above all else. Notably, more than 29 percent of the requests for prescriptions were for opioids. The UR decision on pharmaceuticals was upheld in 92 percent of the cases. Around 25 percent of IMRs were for injections, physical therapy and durable medical equipment. The issues that had the highest rate of IMR overturning a UR decision were requests for evaluation and management services, at slightly more than 79 percent. Certain physicians were known to have a high number of IMRs. The top 10 percent accounted for 85 percent of these requests. 45 percent came from the top 1 percent.
The goal of IMRs is to keep the case out of court and for the decision to be streamlined. The statistics might not be deemed of significant importance to the workers who is seeking benefits, but it can be important as there are certain doctors who are clearly more strident when deciding on a medical request. An attorney experienced in workers’ compensation can help with all aspects of a claim including the UR and IMR.
Source: insurancejournal.com, “California Workers’ Comp Medical Review Volume Fell Slightly in 2017,” March 14, 2018