Workers Comp Zone


Now we know that the California Supreme Court will not be granting review of the Court of Appeals decision in Frances Stevens v. Outspoken Enterprises.

The issue regarding the constitutionality of the California Independent Medical Review system is still in play, with the pending Zuniga case and the Ramirez case out of the Sacramento-based Court of Appeal, 3rd District.

But for a current snapshot as to how IMR is working, let’s turn to a February 2016 report by Rena David of the California Workers’ Compensation Institute. The study focuses on IMR decisions in 2015.

Explaining the methodology of the report, David notes that:

“For this study, the author obtained the 2014 and 2015 IMR determination letters from Maximus Federal Services (Maximus), the Independent Medical Review Organization that is under contract with the California Division of Workers’ Compensation to manage the IMR process. The total number of IMR determination letters issued by Maximus grew from 137,761 in 2014 to 163,826 in 2015 (+19 percent).”

Here are key takeaways from the report:

-IMR determinations seem to be fluctuating each month, but the pattern seems to be from around 12,000 to 15,000 per month in 2015 after a big dip early in the year and a spring spike in numbers;

-the median response time from IMR application to decision letter is between 41 to 49 days;

-in 2015 out of 294,458 IMR decisions, the UR denial of treatment was overturned only 11.4% of the time. That means that 88.6% of the time the IMR reviewer agreed with the UR decision to deny the requested medical treatment;

-pharmaceutical appeals were 49.6% of the IMR requests and of those 89.7% of the UR denials were upheld; the denial rates for compound medications hit a whopping 98% rate;

-the rates for IMR uphold of UR denials really varied very little by year of injury, so that is not a factor;

-the LA area generated 34% of IMR decisions, and the rate of IMR upholding UR denials was the highest among regions (90.6% IMR uphold rate);

OK, you say….much of this is in line with other studies that have been done.

But what continues to catch one’s eye are the stats about individual providers.

The CWCI report notes that:

“IMR determination letters also include the names of the medical providers who requested the disputed medical services. The 163,826 IMR letters issued in 2015 identified 12,759 unique provider names. As in the prior research, the latest data show that a small number of medical providers continued to account for a disproportionate share of the medical service requests that went through IMR in 2015. Exhibit 9 shows that the top 1 percent of medical providers named in the 2015 IMR letters (128 individuals) were linked to 46 percent of the disputed medical service requests, while the 1,276 physicians who comprised the top 10 percent were named in 85 percent of the disputed services that went through independent medical review. Furthermore, a comparison of the results from 2014 found that nearly 83 percent (1,053) of the 1,276 physicians who had the most disputed medical service requests that went through IMR in 2015 were also on the prior year’s list of top volume providers.”

In fact, the report breaks out stats on the top 10 providers. 5 of whom are in Northern California and 5 in Southern California. The top provider, an unidentified Northern California orthopedist, generated 1.9% of the total IMR appeals  (and there was a 91.8% uphold rate on those denials).

One can’t blame patients who may have faith in their doctor, nor lawyers who try to fight for the interests of their clients, many of whom want the things the doctor tells them they need.

But are these doctors on MPNs? How to deal with “outliers” who perhaps don’t understand MTUS or who willfully and massively disregard MTUS standards.

That’s a question that will be debated with more and more frequency.

Stay tuned.

Julius Young