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New Workers’ Compensation Law Leads to Independent Medical Review Process

By Amy C. Leung, Esq.
Associate, Gordon, Edelstein, Krepack, Grant, Felton & Goldstein, LLP

Recently, we informed you about a newly enacted California bill, Senate Bill (SB) 863, which is essentially an overhaul of the state’s Workers’ Compensation system.  SB 863 makes important changes to numerous parts of the system.  Many details have yet to be finalized, as new regulations are being drafted to implement the new law.   Over the next few months, Gordon, Edelstein, Krepack, Grant, Felton & Goldstein, LLP (GEK) will be providing you with more information about the specifics of the new law.   In this article, we will discuss the new rules governing medical treatment disputes. 

Since the last reform in 2004, current medical treatment requests made by doctors have been subject to Utilization Review (UR), whereby insurance companies approve or deny treatment recommendations through an internal review process.  An employee objecting to a UR denial of treatment could either be evaluated by an Agreed Medical Examiner (AME) or Panel Qualified Medical Examiner (PQME) to resolve the dispute. 

Now under SB 863, AMEs and PQMEs will no longer be deciding disputes that arise when UR denies, delays or modifies medical treatment recommendations.  Instead, the State of California will create an Independent Medical Review (IMR) procedure to resolve UR disputes.  This new IMR process has strict timelines and requirements, and gives the employee only 30 days from the date of a UR decision to request an Independent Medical Review of the decision.   If the employee misses the 30-day deadline, the UR denial of medical treatment remains in effect for an entire year (with some limited exceptions).  There will be specific rules governing what documents can be sent to IMR for consideration in deciding the disputed medical treatment request, and required forms that are properly filled out for submitting such documents.

When do all these changes go into effect? All work-related injuries that occur after January 1, 2013 will be subject to this new IMR process.  And, all treatment requests made after July 1, 2013 will have to be resolved by this IMR process, regardless of when the injury occurred
We are hopeful that the new IMR process will result in a more expedient resolution of medical treatment disputes that often arise.   However, we are concerned with the strict time limits placed on an injured worker and the risk of losing the right to obtain needed medical treatment.  We are preparing for these new rules so that our current clients, and future clients, will have the ability to have medical treatment disputes properly and thoroughly reviewed with the hope that much needed medical treatment will be authorized.

GEK attorneys are well-versed and knowledgeable about the many specific rules, exceptions and timelines involved in the complicated Workers’ Compensation system.  Now that there will essentially be a complete overhaul of the system, it is more important than ever to be represented by an attorney who can advocate for you and fight to obtain essential medical treatment.

 

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