The Problem with IMR is UR

We read David DePaolos timely column, "IMR The New Game in Town" (Sept. 24) with great interest, and we wish to suggest a completely different explanation for the current independent medical-review crisis: out-of-control utilization-review (UR). We have witnessed utilization-review denial after denial for many years.

As advocates for injured workers, we spend every day of every week trying to obtain appropriate medical care to assist our clients in returning to work. In our experience, UR is most often used to deny legitimate medical care, which generates disputes and frictional costs.

The underlying fact about the IMR requests is the enormous number of utilization-review denials issued in August of 2013 alone. There were 15,731 reported utilization-review denials, resulting in 15,731 independent medical reviews. The IMR appeals occur because the pre-programmed UR denial machinery is running at full steam, and without reference to the actual merits or costs associated with the treatment request. For example, the cost of UR and IMR for an X- ray is much more costly than the X-ray itself. Anyone outside of our system would be calling for an investigation.

The preponderance of UR denials overrules insurers own doctors, 80% of them are employer vetted and selected. So, of the 15,000 IMR applications in August, 12,000 of them are treatment requests by the employer's own physicians. It is reasonable for injured workers to seek IMR vindication of the employers treating doctor's recommendation, particularly when the treatment is lost for a year if no application is filed. IMR is doomed to fail if invalid, unjust, unethical, and inefficient utilization review continues to run rampant.

We are very concerned that independent medical-review requests in California workers compensation are 30 times higher than group health. The estimated fees collected by Maximus in August alone were $9 million dollars, a projected annual cost of $100 million. We have been alarmed at how many treatment requests by treating physicians do not comply with the rules, resulting in unnecessary delays. We are disappointed at how little education has been offered to treating physicians to get it right.

Under Senate Bill 863, the language of the statute boxes the worker in with only one, limited method of redress: file an IMR application. There are harsh consequences to an injured worker who does not exert their right to file an IMR application. They lose the right to re-request the same medical treatment for 12 months. There are no other appeals processes afforded in the new law for the injured worker if a utilization-review denial is invalid.

The stability of the workers compensation system in part depends on efficient and reasonable treatment cost containment. Workers should have access to quality and effective medical treatment to assure rapid and optimal recovery. When necessary treatment is delayed, both the financial and physical outcome is worse for the employee (i.e., prolonged temporary total disability, higher permanent disability, greater financial loss, greater risk that public benefits will be necessary). And the delay in getting back to work results in a costly, adverse affect on the employer as well.

Consider this: Every single IMR application reflects a rejection of the treating physicians requests for care that he or she believed would help restore the injured worker to health and work.

UR companies exist to control medical costs. But the more reviews a UR company does, the more money it makes. The discretionary function of insurance adjusters to perform their role i.e., adjust benefits including authorization of reasonable medical treatment has been hijacked by the UR industry. In many cases, the adjuster has no discretion, or even involvement, on the review of medical-treatment requests. The ultimate measure of a UR companys "success" is not whether the requested medical treatment was reasonable, but rather how much of the medical treatment was avoided/denied.

We call for an investigation of the UR process to protect the integrity of the dispute-resolution process and assure that it is not abused by carriers at the expense of workers health and costs, which are then passed on to employers in the form of premiums. The current penalty scheme is not sufficient, and the people who are penalized are the injured worker and the employer.

Investigators should examine:

How many cases cost more for UR/IMR than the cost of the recommended medical treatment?

How many UR cases denied multiple treatment requests while the employer was still paying temporary disability compensation and the injured worker remained restricted from returning to work?

How many utilization-review denials failed to follow the protocol that is required of an independent medical reviewer?

Until the UR process is strictly regulated and policed, it will continue to threaten the integrity of the IMR process.

 

Adam Dombchik and Tom Martin are board of director members for the California Applicants
Attorneys Association (CAAA).

 

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