Workers Comp Zone


Delays in the Independent Medical Review process are no laughing matter for workers who are waiting for a determination on treatments sought by their physicians.

Still, I’ve had to chuckle as I read a series of articles in over the last few days about the question of missing medical records in IMR cases.

This saga began when Maximus apparently erroneously e-mailed a document to Workcompcentral that noted that as of March 2015 6,843 cases had missing medical reports. According to the piece by Greg Jones,  Maximus had apparently not received medical records for at least 90 days on 5,021 cases.

Jones noted that he confirmed these numbers with DWC spokesman Peter Melton.

Under the statute and regulations the insurer/employer is responsible for providing relevant medical records to Maximus within 15 days of notice of assignment to Maximus.

In late 2014 the DWC issued a warning to carriers that it would begin to assess penalties for failure to make timely submission of records to Maximus. Here is what the DWC said at the time:

“The Division of Workers’ Compensation (DWC) will initiate the procedure to assess administrative penalties for claims administrator failure to timely submit relevant medical records in cases currently pending Independent Medical Review (IMR).

Under Labor Code section 4610.5(i), DWC is authorized to assess penalties against claim administrators whose conduct has the effect of delaying the IMR process. Under current regulations, Maximus Federal Services, Inc., the organization designated by DWC to conduct IMR reviews, sends the claims administrator a Notice of Assignment and Request for Information (NOARFI) in an IMR case. The notice advises of the relevant medical records to be submitted, which must be provided to Maximus within 15 days of the date on the NOARFI. The regulatory requirements for submitting records can be found at California Code of Regulations, title 8, section 9792.10.5.

Under California Code of Regulations, title 8, section 9792.12(c)(6), failure to submit the records within those 15 days will subject a claims administrator to an administrative penalty of $500 for each day the records are untimely, up to a maximum of $5,000. DWC will send an Order to Show Cause to claims administrators who may be liable for a penalty, with the facts upon which the penalty is based, the penalty amount, and the administrative process for contesting a penalty.

The procedure to assess administrative penalties will commence in cases where there is a failure to timely submit medical records dated on and after December 1, 2014. For IMR cases currently pending at Maximus as of December 1, 2014, the penalty procedure will commence if the relevant medical records are not received on or before December 15, 2014.”

So far (and four months later) the DWC has not issued penalties, however.

The Maximus e-mail that was apparently inadvertently sent to Workcompcentral (or was it inadvertent?) fingers specific non-compliant adjusting companies Broadspire, York and Gallagher.

This report apparently created some consternation, as a number of adjusting outfits claimed that Maximus was making mistakes and refusing to acknowledge receipt of records they claimed they had sent.

Maximus itself refused to respond to detailed questions from Jones.

In one post, prominent blogger David DePaolo urged the DWC “to just do its job”.

But fast forward to today. According to Workcompcentral, Peter Melton of the DWC is now contending that most of the cases with records missing after 90 days are closed cases.

Melton is quoted by Workcompcentral as relying on assurances from Maximus “that the majority of those cases are terminations (closed), either because the treatments in dispute were authorized, the underlying case was settled by compromise and release, the IMR was moot because circumstances changed, or the injured worker or their representative withdrew the request for IMR.”

Melton says that “Maximus indicates”. We are supposed to take their word.

Perhaps that is true, but the accidental e-mail from Maximus documents significant problems with some carriers not sending records.

The moral of this tale is that there is a lack of transparency as to how this IMR program is being administered. Maximus does not consider itself publicly accountable. The DWC has been in no hurry to put teeth into its regulations. And some claims outfits are getting away with it.

What the true numbers are, we don’t know.

At best, the saga doesn’t inspire confidence. At worst, it appears that the system is truly out of control.

If oversight hearings are held, detailed questions should be asked.

I recommend you also check out the most recent post on this by David DePaolo:

Julius Young