In 2004, the medical landscape in California (CA) changed significantly for anyone involved in treatment of a person injured at work. Utilization Review (UR) became mandatory, and the presumption of correctness for the extent and scope of treatment shifted from the injured worker’s treating physician to the American College Occupational and Environmental Medicine (ACOEM) guidelines. The ACOEM guidelines are evidence-based treatment guidelines developed through extensive research with the goal to improve or restore the health of the injured worker.  Workers’ Comp Insurers and TPAs had to ensure they had a UR program to address the questions of medical necessity.

The UR process in CA continued to evolve and in 2012, Senate Bill 863 created an Independent Medical Review (IMR) process as an independent appeal avenue for disputed UR decisions.

What is an Independent Medical Review?

An independent medical review (IMR) is a review of a medical claim(s) by a physician to determine the outcomes of those claims for workers comp or disability insurance payers. Physicians who perform IMRs must be board certified and in active practice in that same area of treatment.

The CA Department of Industrial Relations publishes periodic analysis of the IMR data with the most recent encompassing 2017 results.

Here are some key findings of that analysis:

  • Over 172,000 decisions were issued in 2017.
  • The original UR decision was upheld by IMR over 86% of the time. About 5% of the UR decisions were partially overturned and about 8% were completely overturned. These outcomes are consistent with 2016 results as well.
  • 95% of IMRs reflected injured workers who had legal representation.
  • Case outcomes did not appear to be impacted by legal representation nor by the age of the injury.
  • The most common treatment categories submitted for IMR review were:
  1. pharmaceuticals (42.6%)
  2. diagnostic testing (16.2%)
  3. rehabilitation (14.1%)
  • Not surprisingly, opioids represented the largest portion of pharmaceuticals submitted, followed by topical analgesics.
  • IMR reviews were completed within 10-14 days on average after medical records were received.

 

The good news is that the IMR process in CA does seem to be working. They have enough qualified reviewers to get through a large volume of cases every month well within the 30 days required by the regulations. The better news is that UR companies also seem to be getting it right with evidence-based UR decisions being upheld by an independent reviewer over 86% of the time.

For more information about Shearwater Health’s UR services, click here.

Marcia Headley, RN BSN CCM