Workers Comp Zone


A DWC newsline summarizes he proposed changes in the IMR regs: … f#zoom=100

One particular recent concern about IMR has been the reports that Maximus was acting on cases where the carrier had failed to submit medical reports.
I wrote about that several months ago in a post titled “Sandbagged”: … 712-190054

Will the revised proposed regs solve this problem?

Not necessarily, it appears. As drafted, the proposed new regs do not flatly prohibit Maximus from making a determination where the carrier has either willfully or negligently failed to provide required medical records.

It needs to be emphasized that it is the carrier that has the medical reports and records.

Unrepresented workers do not have those documents. And where a worker is represented, the adjuster may not have served all of those documents on the applicant attorney despite rules that require timely service of medical reports.

Without contextual medical records, how can Maximus reviewers provide quality medical decisions?

They can’t, of course.

Yet the proposed rules appear to allow Maximus to move forward in such decisions, rendering a decision.

What the rules do do is clarify that “upon receipt of credible information” of carrier failure to comply, a process to assess penalties against the carrier shall ensue.

That proposed language can be found in the following :

Section 9792.10.6(j): Upon receipt of credible information that the claims administrator has failed to has failed to comply with its obligations under the independent medical review requirements the Administrative Director shall, concurrent or subsequent to the issuance of the final determination issued by the independent review organization, issue an order to show cause for the assessment of administrative penalties against the claims administrator under new section 9792.12(c)

Reg 9792.12(c)(4) would provide for a $500 per day penalty for failure to submit the required information to Maximus, up to a maximum penalty of $5,000.

Wouldn’t it just be easier to draft a rule with some teeth?

The rule could provide that an IMR determination where the records were not submitted is null and void and must be redone. Or a rule could say that if the carrier breaches its obligation to submit information, the applicant prevails on the issue by default.

Another approach that could have been taken would be to provide a grace period to applicants and their attorneys. If Maximus received no records whatsoever or if Maximus noted that key records were missing, notice of that should be forwarded to the worker to provide an opportunity to cure the problem.

Stiffening penalties is a weak solution. Most unrepresented workers are unlikely to be sufficiently well informed as to complain in order to trigger penalties. How these penalties will be handled, and in what format complaints can be rendered is not made clear.

Moreover, if the rationale for IMR in the first place is to render quality medical decisions, shouldn’t any decision rendered without records be suspect.

The rules would also reduce the volume of records that a carrier is required to send to Maximus. The current regs require that one year of current treatment records be provided. Proposed reg 9792.10.5 would reduce that to require that only records going back 6 months prior to the disputed treatment request be provided.

The proposed IMR regs can be found here:

Public comments on the proposed regs are being accepted until 5 p.m. on October 11, 2013. Send your comments to [email protected]

Stay tuned.

Julius Young

Category: Medical treatment under WC