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The California Division of Workers’ Compensation on Friday revised its proposed independent medical review rules to add new penalties and to require a determination on whether a dispute is eligible for review be made within 15 days.The changes to the rules appear to address two concerns about the new process created by SB 863 to resolve disputes over utilization-review determinations. Injured workers and their attorneys say it’s currently taking about two months to...

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Comments (9):
“If the carriers send three feet of records to MAXIMUS for each IMR, the system will come to a screeching halt. Need a 300 page limit on represented cases. If case too complex to decide after reading 300 pages - then include a request to augment which MAXIMUS can look at if needed.”
By: John A. Don esq., 09/30/2013 02:09:00 pm

“Don....The WC system has already come to a skreeching halt because of the back log at Maximus. This is why many injured workers are trying to seek treatment under the old self procured system, but finding no -one to treat them. The system is going to emplode soon if the DWC/DIR does not impose penalties on Maximus. But no-one cares !!”
By: Anonymous, 09/30/2013 05:09:00 pm
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“if there are penalties for missing guidelines, I am sure Maximus will meet the deadline to avoid penalties. The goal of getting decisions quickly will be reached. However, I am concerned about an unwanted effect of quick, timely decisions that are made will only superficially examine the facts of the case. The injured worker will not be able to dispute whether the reviewer made a timely but inadequate decision based on all of the facts”
By: michael kesselman, 09/30/2013 02:09:46 pm

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“The big issue has nothing to do with documentation, timeliness or penalties. The big issue is why there a staggering number of disputes in WC compared to group health (GH). Rough calculation, there are 3,000 times the rate of disputes in WC relative to GH. Put another way, given the 20-30 times larger number of group health transactions, DMHC would face about 3,000,000 IMRs per year at last month's DWC rate. GH would never allow that and apparently knows something WC doesn't. Answer, get all the comp stakeholders in a room with Blues, Kaiser, Healthnet and others and figure out how to do comp differently. That comp tolerates this level of disputes is astounding. Time to get at the root causes, not the process for resolving disputes.”
By: Frank Neuhauser, 09/30/2013 03:09:16 pm

“The carriers drafted this law 100%. This is what they want. More justification for huge rate hikes. It is amazing how the carriers are increasing the money they are taking in on premiums at the same time the stock market is at an all time record high. Lucky timing guess. Mr. Neuhauser is there any data the stock market and WC rates?”
By: Anonymous, 09/30/2013 04:09:04 pm
“Dr. Neuheuser, medical treatment in comp is a matter of rights created by state law, as opposed to a private contract between parties. The right of workers to sue for damages was taken away in exchange for the statutory right to comp benefits. Moreover, claims litigation in comp has been a highly adversarial system where claims examiners would "step over a dollar to save a dime" (object to an MRI but keep paying TTD. I'm sure the insurance industry would also like to have mandatory arbitration of all PI claims. Maybe in Jerry's next term. ”
By: John Dunn, 09/30/2013 06:09:16 pm
“It's interesting to note the comments, most of which have various levels of validity by looking at the situation from different angles. However, I wonder how many of the commentators have actually submitted billings to Maximus on the PPO/Health Indemnity side and watched how they determine medical necessity? They use essentially the same model as the current WC system for reviewing submitted reports/documents to determine medical necessity. The results are uniformly horrendous with inordinate delays, incorrect citations to the terms of PPO and other contacts, non-nonsensical results of file reviews, constant arguments with physicians, etc. The delays have already started. Industry-wide, Maximus is considered a huge, pathetic joke, used as a tool of the insurance companies to reduce or deny treatment. After speaking with other billing and collection companies, this attitude appears to be the industry rule rather than the exception. One must remember that the volume of bills reviewed by Maximus is absolutely huge and, to make a profit (believe me they are in it for the money), the cases must be turned as quickly as possible. The commenter noting there should be a 300 page review limit has apparently never dealt with Maximus since, believe me, no reviewer will EVER review anything even close to this volume of documents. In fact, as I'm sure most of you are aware, a recent series of determinations in favor of the carrier was made sans carrier-supplied documents, (by the way, WHO pays for these reviews?). The "hasty review" noted by other commentators is the ONLY type of review that can realistically be expected considering the volume of recent applications. Think this is unusual? Don't, this is industry standard. Don't agree with the putative "extensive review" results conducted by the IMR? Too bad. Try an appeal on the grounds available. Remember, these doctors are paid per case, as is Maximus. As they say in car sales, "you gotta move the iron" to make a profit. Finally, I agree that Maximus will "expedite" all of the WC reviews as much as possible since penalties exist and payment thereof cuts into the bottom line and they wish to give the appearance of performing up to the standards expected by the DWC. After all, they have a no-bid contract for the next two years and clearly would like to extend it as far as possible. What can we expect in the future? Unless legal action is somehow brought to ensure adequate, timely, and valid reviews (I've heard lack of due process, constitutionality issues, etc.), we will get what everyone else gets in the PPO/Health Indemnity arena-absolute unfounded junk. Unfortunately, we are dealing with the health and welfare of injured workers requiring the very best the medical community has to offer regarding decisions of medical necessity that may affect the rest of their lives. However, in our experience and those of others, this does not appear to be a top priority of Maximus. ”
By: MARTIN PRYAL, 09/30/2013 07:09:58 pm
“Maximus would not be so busy if 1) physicians wrote reports to include the information necessary for UR to determine if the treatment falls within guidelines, 2) physicians actually reviewed the denials, provided the information and/or participated in the peer-to-peer, or 3) A/A's actually read the denial reasons and forced their doctors to adhere to guidelines instead of rushing to file for an IMR. As an example, I'm estimating 8 out of every 10 medication denials are because the doctors do not address the efficacy of the medications, the reason it is still needed years after the original injury, or what is being done to wean the patient from the medications.”
By: YORK RISK SERVICES GROUP , 10/01/2013 05:10:09 pm
“Comp Doctors are the driving force behind all the IMR appeals not the patients. With a buck in mind they are telling the patients to file a appeals for the crappy physical therapy, Acupuncture, Epiderals, Compound meds (bunch of crap), etc. My kaiser doctor would never order physical therapy or acupuncture, compound meds (LOL) unless I really needed it. When doctors have a financial interest in the referrals, it screws up the system.”
By: Anonymous, 10/01/2013 09:10:50 pm
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