Workers Comp Zone


The California DWC’s latest report on Independent Medical Review (IMR) is now out (see link below).

The report analyzes data on IMR during 2014 and 2015. What can we learn from it?

There’s clearly an unremitting high volume of disputes over treatment denials by UR. The gross number of IMR applications averaged over 20,000 a month. And even after factoring out duplicate IMR applications and ineligible applications (due to untimeliness or other reasons) there were an average of 12,837 per month.

So the volume continues far higher than anticipated at the inception of IMR.

In the first few years the timeliness of IMR was atrocious. It has improved substantially so that by mid-2015 the IMR decision was issued on average within 10 days of when complete medical records were received. The report credits that improvement to implementation of electronic submission of medical records and also notes that the DWC fined some claims administrators who were late in submitting records. At its best, in late summer 2015 , the average number of days from assignment of IMR to a final determination letter fell to 43 days.

But the report (at page 8) notes some significant deterioration in these numbers during the last quarter of 2015. This is attributed to “a surge of records” received by Maximus “for many older cases that were still open”. No further analysis is offered as to why by the end of 2015 the average time from complete medical records went from 10 days to 24 or why the average age from assigned date went from 43 days to 61 days.

That’s quite a jump. So there must have been many many “older cases still open”  which raises questions about whether parties in those cases were fined and what the DWC/Maximus did or didn’t do to follow up on those. After all, on page 10 of the report the claim is made that “By the end of 2014, any backlog that had accumulated was erased….” although elsewhere the report notes that “At the end of 2014, 14,135 cases remained open…”  This would seem to imply that by the fall of 2015 there were a lot of  cases still open from early 2015 in which case one wonders whether the mid -summer 10 day (from records receipt) & 43 day  (from assignment) numbers are accurate after all.

Readers can look at the report themselves to determine whether these numbers make sense or whether your blogger is misconstruing the numbers.

In any event it will be interesting to see whether the better numbers in mid 2015 were temporary or whether the poorer results at year’s end are more the norm.

A number of the other findings in the report aren’t really that newsworthy. For example, pharmacy disputes constitute a big slice of the IMR application totals. And Los Angeles and the Inland Empire  are among the areas that account for a disproportionate amount of IMR applications.

But an interesting statistic was that attorney representation made no difference in overturning UR denials. In both 2014 and 2015 unrepresented workers who appealed to IMR had better results (winning 7% and 10% of the time respectively). However, workers without an attorney may never have been able to/never bothered to appeal the UR denial, so some workers clearly benefit from the representation.

Overall, workers fared poorly in appeals. In 2014 only 9% of treatment denials were overturned by IMR. In 2015 only 11% were overturned by IMR.

The report attempts to make the case that medical reporting is often inadequate to support the treatment requested. This was done by analysis of a 53 case sample of opioid requests (under the old opioid guidelines, not the ones adopted in 2016).

The bottom line in this 53-case analysis? Prescribing doctors performed an inadequate job of documenting that the worker met the criteria for opioid use.

Prescribers failed to adequately assess pain relief, functional improvement status, documentation of side effects, and behavioral problems.

The 53-case sample is pretty small, but I must say I’m not surprised, as many prescribers continue to be unaware of or unwilling to work with the MTUS treatment guidelines that have been in effect for quite some time.

Perhaps the recently announced DWC online physician continuing education module will help educate physicians on MTUS and what level of documentation is needed to navigate the system.

It’s important to note that this report doesn’t answer many important questions surrounding the medical treatment dispute resolution model in California:

-To what extent if any are UR and IMR denials contributing to delays in return to work and to longer periods of temporary disability?

-Are claims administrators submitting an adequate amount of records to UR and IMR for reviewing physicians to make an accurate and adequate decision?

-Is there any way to assess the effect of UR and IMR on ultimate delivery of quality health care?

-Excluding first-aid cases and minor lost time injuries, what proportion of treatment requests are submitted to UR in the first place?

-How does the cost of UR and IMR correlate with savings on medical treatment costs?

-How many IMR determinations are being successfully appealed at the WCAB, and what results were generated by a second IMR?

-Is the online posting of IMR decisions and the online search tool leading to any demonstrable change in what treatments are requested and approved?

-How have changes in treatment guidelines affected IMR uphold rates, if at all?

There may be tweaks, but IMR is here to stay. But in the meanwhile it would be good to get more data on some of these questions.

Here is the link to the DWC report on IMR:

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Julius Young