IMR in 2016

When an employee is injured on the job, he or she will need to get medical treatment to proceed with a workers’ compensation claim. The physician will make an assessment of the injury and decide what type of course of treatment will be best to treat and hopefully cure the injured employee. In some situations, an employer can request an Independent Medical Review of the physician’s diagnosis and treatment plan. When a claim is made for workers’ compensation, the claim must go through a “utilization review” process in order to confirm the treatment is medically necessary before the claim is paid out. If the claim is denied, the employee may request an IMR. If an employer believes the claim should not have been approved, the employer may request an IMR. The purpose of instituting the IMR system was done with an eye toward reducing workers’ compensation disputes and speeding settlement, in order to help ease the congestion in the court. A recent analysis done of IMR volume shows that the process is perhaps not meeting its intended purpose.

The California Workers’ Compensation Institute conducted an analysis of almost half a million IMR decision letters from 2014, 2015, and 2016. These letters were from applications submitted to the state after a utilization review physician’s medical service was modified or denied. In 2016, IMR was at record high levels, with 10,477 more cases in 2016 than in 2015. The IMR analysis showed that in over 90% of cases, the IMR upheld the decision to modify or deny a requested medical service. The types of services did not change much, with prescription drug requests comprising over half of all IMRs, 28.5% of which were for opioids. The rate at which the IMRs upheld the decision made by the utilization review varied from 78.9% for evaluation services to 93.6% for acupuncture. The analysis also found that IMR requests varied widely by geographic region, with Los Angeles County and the Bay area representing a disproportionately large amount of IMR requests vis a vis their percentage of involvement in workers’ compensation medical services across the state. Similarly, areas with low population typically had a disproportionately small amount of IMRs, as did Orange County and San Diego.

If you own your own business, you need an experienced attorney to help you navigate the system. Call us today at (714) 516-8188. I can help you understand your business’s obligations and the claims process.

Timeliness of IMR

When an employee sustains a work-related injury, a complicated set of procedures is set into motion. An employee must receive treatment, an employer must complete paperwork, take witness statements, and submit a claim to its workers’ compensation insurance provider. While an employee receives medical treatment, his or her expenses for medical appointments, continuing treatment, and prescription medication will be submitted to the workers’ compensation insurance company. The claim will then go through a process called “utilization review,” wherein the insurance company will decide if the course of treatment is medically necessary. If the insurance company decides that the treatment is not necessary, it may modify or even outright deny the request for treatment. In such a case, the employee may then request an Independent Medical Review, or “IMR.”  During an IMR, the employee’s medical file is submitted to an independent medical professional who will then review the file and make a determination whether the utilization review made the right decision as to whether the treatment should be modified or denied.

California Labor Code 4610.6 provides several different time requirements for IMRs. Subdivision (d) provides that for any medical dispute not involving the drug formulary, the IMR must be conducted within thirty days of receipt of the request for review and the supporting documentation. A recent case styled Baker v. Workers’ Compensation Appeals Board, Sierra Pacific Fleet Services, et al. took on the issue of timeliness of IMRs and the impact that the failure to conduct the IMR in accordance with the statute’s timelines could have. In that case, the worker was injured after falling over some tools at work. He injured his knee, neck, and shoulder. His physician prescribed certain medication, but a utilization review recommended they be denied. On March 19, 2014, the worker requested an IMR. The administrative director failed to uphold the denial until July 21, 2014. The worker appealed this determination and the workers’ compensation judge ordered a new IMR. The new IMR again upheld the utilization review. The worker again appealed. The WCJ determined that the IMR determination was untimely under 4610.6, but that did not mean that the IMR was de facto invalid. The higher court agreed, and held that “an untimely IMR determination is valid and binding on the parties.”

The workers’ compensation process can be complicated. If you have a question about your case and the IMR process contact me today at (714) 516-8188.

Frances Stevens v. Outspoken Enterprises and Home Health Care

Workers’ compensation is designed to and does cover a wide variety of treatment and types of care for workers who have sustained a work-related injury. Workers and providers can apply for payment for treatment associated with the care, and in some cases this will include home health care. Home health care may be required where an employee sustains an especially severe injury. In Frances Stevens vs. Outspoken Enterprises, Inc. (State Compensation Insurance Fund), the issue was whether it was proper for the Administrative Director to deny the plaintiff’s request for home health care based on an Independent Medical Review.

In this case, the plaintiff employee sustained a work-related injury. After being examined by her own physician, the physician recommended and requested home health care services. The employer requested an Independent Medical Review of this determination. The IMR applied the 2009 Medical Treatment Utilization Schedule Chronic Pain Medical Treatment Guideline and denied the plaintiff’s request to have the cost of her home health care covered under worker’s compensation. The court in a May 2017 opinion noted that there was extensive evidence that her need for home health care was “compelling,” and included extensive expert testimony to that effect. The court determined that the Administrative Director was wrong in applying the guideline and sent the case back to the lower court for further determination. The court stated that if the lower court decided the Administrative Director was wrong in denying the home health care after reviewing the available evidence, it may be appropriate to have a new IMR conducted.

The court ultimate determined that the 2009 Medical Treatment Utilization Schedule Chronic Pain Medical Treatment Guideline was not a “medical treatment necessity standard,” but rather was a standard for Medicaid reimbursement, and the decision was outside the Administrative Director’s authority, pursuant to labor code section 5307.27. The court went on to point out that it was contrary to labor code section 4600(h) and California case law. The court held that the guideline should not have been “summarily applied.”  Instead, the request should have been evaluated within the requirements of 4610.5(c)(2) and the MTUS.

 

If you have questions about the workers’ compensation system and whether your business is obligated to cover certain types of care, you should discuss this with an experienced attorney. Call us today at (714) 516-8188 for an appointment to talk about your business.

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