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Independent Medical Reviews in California

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When a dispute is raised regarding a denied workers’ compensation claim, the original medical treatment is evaluated through California’s independent medical review (IMR) program. The recently reformed law addresses any injury that occurred in the past. Many states process workers’ compensation claims through the court system, but by allowing physicians and healthcare experts to asses these rebuttals, IMRs have proved an excellent cost-saving initiative.

IMR in California

These reviews help businesses, medical facilities, and insurance companies facilitate claims, but the process can still be a bit confusing for newcomers. And for employees who have been injured, dealing with a denied claim is still challenging. Here are a few questions and answers to help you understand this process:

How do you file a request for medical treatment through this program?

A preliminary checkup identifies what is medically necessary for the affected party and whether or not a workers’ compensation claim should be approved. This is called a “utilization review.” If an injured employee is denied treatment and compensation at this point, he or she can request an IMR, which is essentially a second look at the accuracy of the utilization review.

To submit a request for an IMR, workers must:

  • Submit an IMR application form, which can be picked up from a claims adjustor.
  • Attach a copy of the utilization review in question.
  • Send the documents within 30 days of the preliminary checkup.

Who pays for IMRs?

Companies required by California law to provide a workers’ compensation program and compensate workers for work-related injuries pay for these additional reviews. The amount a business pays depends on when the requests are submitted, when the results are needed, and how many medical professionals are needed to review the claim. Though these are somewhat expensive (approximately $350–$515 per IMR), it is an incredibly affordable alternative to court hearings.

There are three types of IMRs, which affect turn-around times and costs:

  • Standard IMRs, involving non-pharmacy or pharmacy-only claims
  • Expedited IMRs, involving non-pharmacy or pharmacy-only claims
  • Terminated IMRs, which are terminated and dismissed and may be sent to a medical professional for further review

What happens after an IMR?

If the utilization review is eligible for an IMR, a Notice of Assignment and Request for Information will be sent out. This simply informs the parties that the review has been approved for an IMR. Medical records must then be provided for the assigned evaluators. Next, these specialists will review the claim to determine whether or not the utilization review was accurate. Based on their findings, an employee’s claim will be rejected or damages will be deemed eligible under the state’s workers’ compensation laws. The worker will then receive a payout offer, which he or she can accept or renegotiate.

Fighting for Your Rights as an Injured Worker in California

IMRs are an excellent way to dispute a workers’ compensation claim without going through the court system. However, simply requesting an IMR doesn’t mean your claim will be approved. While this is an important process, you may still not receive the compensation needed to fully recover; you may need to pursue additional legal actions to account for medical equipment, pain and suffering, and other costs associated with an injury.

If you run into this problem, reach out to an experienced legal team in California as soon as possible. There are many details that can affect your claim, such as whether or not the IMR application form was fully completed and filed with the correct application type (e.g., expedited or regular). Submitting this information inaccurately can significantly affect the results of your claim. For the best possible settlement, work with experts in the field. Start with a free consultation by reaching out to us today.