San Francisco, CA – The Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) recently posted a progress report on the Department’s Independent Medical Review (IMR) program. IMR is the medical dispute resolution process for the state’s workers’ compensation system that resolves disputes about the medical treatment of injured workers.
The report describes IMR program activity in 2019, the seventh year since the program was implemented.
The organization administering the program, Maximus Federal Services, Inc., received over 222,000 IMR applications, and issued almost 164,000 Final Determination Letters, each addressing one or more medical necessity disputes.
Key highlights:
- The monthly average length of time to issue an IMR determination after receipt of all medical records ranged from 7 to 8 days throughout 2019.
- An average of 13,600 IMR decisions were issued each month.
- 93.5% of all unique IMR applications filings were deemed eligible for review.
- Treatment request denials were overturned at a rate of 10.4%, with specialist consultations, office visits and mental health services overturned most often.
- Pharmaceuticals accounted for 36.7% of treatment requests sent for IMR with opioids comprising nearly one of every three pharmaceutical requests.
- Guidelines contained in the Medical Treatment Utilization Schedule continue to be the primary resource for the determination of medical necessity.
View the Report: CA DIR DWC: 2020 IMR Report: Analysis of 2019 Data (PDF)
Source: CA DWC