Following an incident at work wherein an employee sustains a work-related injury, that employee may need to seek medical treatment. A workers’ compensation claim is almost sure to follow shortly thereafter. A worker may be entitled to have the costs of his her or medical appointments and treatment covered by the employer or the employer’s insurance under the workers’ compensation system. However, in some cases, there may be a dispute between the employee and the employer about whether a particular injury is of such a nature as to be covered under the workers’ compensation claim. An Independent Medical Review (IMR) is one way that these disputes may be resolved.
Once an employee sustains a work-related injury and gets involved in the workers’ compensation system, a request for a particular course of medical treatment must pass through a “utilization review” procedure. This review process is to make sure that any treatment prescribed by the treating physician is actually medically necessary to treat the work-related injury. In some cases, the utilization review board may modify or deny the treatment recommended by the doctor. If this happens, the injured employee may request that decision be reviewed through the IMR process.
Upon receipt of denial by the utilization review board, an employee may request an IMR by filling out and faxing in specific forms that will be provided to the employee. The state will then decide within thirty days if an IMR is appropriate in the particular case. If it is decided that an IMR is appropriate, a physician will be assigned to the employee’s case. Note that this is a doctor chosen by the state, and not by either the employee or the employer. The employee, employer, and insurance company will have the chance to send supporting documentation to the independent physician. The independent doctor will review all of this documentation and then make a determination as to whether the treatment prescribed by the employee’s own physician is actually necessary to treat the work-related injury. The independent doctor does not actually examine the employee at all. It is all done through examination of medical records and documentation. If the independent doctor does decide that the treatment is necessary, then the treatment must be then authorized by the insurance company within five days of receiving the IMR decision. The overwhelming majority of IMR decisions uphold the determination initially made by utilization review.
If you have questions about your business and workers’ compensation, contact me today at (714) 516-8188. I am highly experienced in guiding my clients through this complicated area of law.