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Understanding Independent Medical Review: Fighting for Medical Care

By David A. Goldstein, Esq.  

One of the most significant ways Senate Bill (SB) 863 has changed California's Workers' Compensation system is the creation of the Independent Medical Review (IMR) process. The following is a rundown of how the system works.

Independent Medical Review: learning the basics.

When an injured worker files a Workers' Compensation claim and is seen by a doctor, that physician must request medical treatment using a new form called a Request for Authorization form (RFA). This form is sent for Utilization Review (UR)—a company paid for by the insurer that reviews the doctor's request for treatment. The treatment request can be delayed, denied or accepted.

If the treatment request is denied, an Independent Medical Review (IMR) is conducted by a private company (called Maximus) hired by the state of California to review the request for treatment. The IMR application must be submitted within 30 days of the UR denial.

The law requires the employer to send what they consider to be necessary medical information to assist in determining if the medical treatment is necessary. The employee and/or the employee's attorney have a right to also send relevant medical documentation to assist an IMR. The employer and the employee have the same 15-day timeline to provide the documentation.

There are very limited ways to appeal an IMR determination, and there are only 30 days to do so. If there is no basis for appeal, in most cases an IMR decision stands for a year. Meaning, the injured worker cannot receive the medical care specifically requested by the doctor. 

It is clear with the substantial changes in the law brought about by SB 863 that it is imperative now more than ever to consult with a skilled Workers' Compensation attorney, such as those at Gordon, Edelstein, Krepack, Grant, Felton & Goldstein, LLP (GEK) to protect your rights if you are injured on the job. If you have questions about your legal options, please click here or call 213-739-7000.



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