Oakland, CA – The number of independent medical reviews (IMRs) used to resolve California workers’ compensation medical disputes rose 4.4 percent in the first half of 2018 compared to the first half of 2017, though once again in more than 90 percent of the cases the independent medical review physician upheld the utilization review physician’s modification or denial of treatment.
Under California law every workers’ compensation claims administrator must have a Utilization Review (UR) program to assure that the care provided to injured workers is supported by clinical evidence outlined in medical guidelines adopted by the state. Most treatment requests are approved by UR, but in 2012 state lawmakers adopted IMR to give injured workers a chance to get an independent medical opinion on treatment requests that UR physicians deny or modify. The latest review of the IMR process by the California Workers’ Compensation Institute (CWCI) found that 89,843 IMR decision letters were issued in the first half of 2018 in response to applications submitted to the state after a UR physician modified or denied a medical service request — an increase of 4.4 percent from the number of letters issued in the first six months of 2017. The average number of primary treatment decisions included in those letters remained unchanged at 1.8 decisions.
Although IMR volume was up in the first half of this year, IMR outcomes showed little change. After reviewing the medical records and other information provided to support the request, IMR doctors upheld the UR physician’s modification or denial of the service 90.7 percent of the time, in line with the 91.2 percent uphold rate from 2017. As in the past, prescription drug requests represented nearly half of this year’s IMR decisions, led by opioids, which accounted for 32.3 percent of the 2018 prescription drug IMRs – up from 29.7 percent in 2017 – an increase that followed the adoption of new opioid and pain management guidelines in late 2017 and implementation of the workers’ comp formulary that took effect January 1, 2018. Requests for physical therapy; injections; durable medical equipment; diagnostic imaging; and surgery together comprised a third of the 2018 IMRs, but no other medical service category accounted for more than 3.5 percent of the disputed requests. The 2018 uphold rates for the various service categories range from 77.8 percent for psych services to 93 percent for acupuncture.
The latest data again found that a small number of physicians continue to account for most of the disputed medical services that go through IMR. The top 10 percent of physicians identified in the IMR decision letters issued in the first half of this year (1,190 doctors) accounted for 86 percent of the disputed service requests during that period, while the top 1 percent (119 providers) accounted for 44 percent of the disputed services.
CWCI has published additional analyses and graphics from the study in a Research Update Report, “Independent Medical Review Decisions: January 2014 Through June 2018,” which CWCI members and subscribers can access at www.cwci.org and others can purchase from the CWCI store at https://www.cwci.org/store.html?si=259.