Oakland, CA – An analysis of the California workers’ comp independent medical review (IMR) process used to resolve medical disputes finds that in 2016, IMR physicians once again upheld about 90% of utilization review (UR) physician’s modifications or denials of treatment, yet IMR volume continued to grow, climbing 6.5% last year.
The California Workers’ Compensation Institute (CWCI) analysis is based on a review of data from 477,045 IMR decision letters issued in 2014, 2015, and 2016 in response to applications submitted to the state after a UR physician modified or denied a requested medical service. State lawmakers who included IMR in the 2012 workers’ comp reforms expected the process would reduce workers’ comp treatment disputes once doctors, attorneys and other participants came to understand which services could be approved because they meet evidence-based medicine standards. Three years in, however, IMR volume is at a record high, as the Division of Workers’ Compensation reports there were 10,477 more cases in 2016 than in 2015.
The 2016 IMR outcomes data show that IMR physicians upheld the UR doctor’s modification or denial of a requested service 91.2% of the time, which was up from an 88.4% uphold rate in 2015 and matched the rate noted in 2014. The mix of services reviewed by IMR physicians in 2016 showed little change from the two prior years, as prescription drug requests (28.5% of which were for opioids) again accounted for nearly half of all IMRs, with UR modifications or denials of pharmaceutical requests upheld 92.5% of the time.
Notably, requests for compounded drugs (typically gels or creams) did represent a declining share of the 2016 prescription drug IMRs, as they fell from 8.0% of the 2015 determinations to 6.2% last year, which may have to do with their consistently low IMR overturn rate (IMR physicians deemed them not medically necessary 99% of the time in 2014, 2015, and 2016). Requests for physical therapy, injections and durable medical equipment together represented about 24% of the 2016 IMRs, while no other medical service category accounted for more than 5% of the disputed requests. Among the medical service categories, uphold rates in 2016 ranged from 78.9% for evaluation and management services (primarily referrals for consultations) to 93.6% for acupuncture.
As in the prior 2 years, the analysis found that most of the disputed medical services that went through IMR in 2016 were requested by a small number of physicians. The top 10% of physicians named in the 2016 IMR decision letters (1,248 physicians) accounted for 85% of the disputed service requests, while the top 1% (125 providers) accounted for 44%. Significant geographic variation was again evident as well, as 32.8% of the IMR decision letters were addressed to Los Angeles County recipients even though the region only accounted for 23.6% of all workers’ comp medical services in the state. IMR volume also was disproportionately high in the Bay Area, which accounted for 20.1% of the IMR letters vs. 15.2% of the medical services; while less populated regions of the state had a disproportionately small share of the IMRs, as did the Inland Empire, Orange County and San Diego.
A complete analysis of the latest IMR results has been released in a CWCI Spotlight Report, “Independent Medical Review Decisions: January 2014 Through December 2016.” Institute members and subscribers can download the report and a summary Bulletin at www.cwci.org, while others can purchase a copy for $24 at www.cwci.org/store.