CA Workers’ Comp IMR Reaches Record High in 2016

The California Workers’ Compensation Institute recently released an analysis of the state’s independent medical review (IMR) process over the past several years. Results of the analysis indicate that the process may not expedite workers’ compensation treatment programs in the way initially thought. In 2016, the volume of IMR requests hit an all-time high despite a few changes in treatment recommendations.

Background on California’s Medical Treatment Review Process

When you file a worker’s compensation claim in California, employers and insurers use a utilization review (UR) process to determine if recommended treatments are medically necessary. Much like personal medical insurance, the workers’ compensation insurers can’t approve every treatment a worker’s physician recommends. In our state, the law requires that either workers’ compensation administrators or employers use a UR program to ensure fair benefits in each claim.

If the UR physician denies, changes, or delays the treatment request, the injured employee can request an independent medical review. The state adopted the IMR process in 2013 to resolve treatment disputes within the worker’s compensation system instead of court. If an injured employee requests an IMR, the employer must pay for the review.

When enacted, the state believed that the IMR process could meaningfully reduce the number of disputes in the workers’ compensation system. As the IMR process set a precedent, treating physicians, program administrators, and others could better gauge the medical necessity and approval-likelihood of many treatments. The information that the state’s workers’ compensation institute released for 2016 shows an opposite trend, indicating that the IMR process may not meet its expected goals.

Exploring the IMR Analysis

To build the analysis, the California Workers’ Compensation Institute combed through 447,045 IMR decision documents from 2014 to 2016. The results of the analysis, “IMR Decisions: January 2014 Through December 2016,” concluded that:

• The number of independent medical reviews is at an all-time high. In 2016, IMR physicians reviewed 10,477 more cases than they did in 2015 – a 6.5% increase.
• In 2016, IMR physicians supported over 90% of the UR decisions they reviewed compared to an 88.4% support rate in 2015.
• The types of treatments reviewed did not meaningfully change over the three-year period. In California, opioid prescriptions account for almost half of all IMR requests.
• A small percentage of treating physicians account for the majority of IMR requests. The analysis showed that the 10 most commonly named treating physicians in requests accounted for 85% of all IMR decisions handed down in 2016.
• A significant volume of IMR requests was highly concentrated in areas of the state with relatively few overall worker’s compensation claims and services.

The analysis data raises more questions than it answers. This year, attorneys, program administrators, and law makers will likely explore why treating physicians with experience using the IMR process continue to file requests for the same treatments and why the volume tends to center on certain geographical locations (the Bay Area and Los Angeles County) and a small group of treating physicians.

Engaging in an Independent Medical Review

The analysis reveals trends across hundreds of thousands of IMR requests, but injured workers must fight their own battles in the system every day. If a treatment dispute arises, take steps to protect your right to coverage.

Understand your medical history, current diagnosis, and the reason for a treatment recommendation so you can accurately relate information during the independent medical review exam. Initial and continual workers’ compensation benefits often depend on a patient’s willingness to work within the system. Honestly and courteously relate your experience. Although the IMR physician has your file, he or she may not read it thoroughly or fully understand your situation. The one-time exam may be your only opportunity to overturn a coverage decision.

A multifaceted review process should ensure fair treatment, but the system doesn’t always work like it should. If you were unfairly treated at any point in the process, consider discussing your claim with an Orange County workers’ compensation attorney.