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California's independent medical reviewer last year upheld utilization review decisions and denied more than four out of five treatment requests that were brought to it, according to a Division of Workers' Compensation report.

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Comments (18):
“6.9% were surgical the rest for meds, tests, consults and therapy . 85% denial. and it takes months or maybe a year. How does anything get done. If I want a consult within my mpn, I must request it through UR/IMR. If I ever get it, I probably won't need it. same for meds, MRIs, therapy. At some point, this can harm patients. What if the patient has a stiff shoulder post op and needs more therapy or a brisement. He may never get his motion back if too much time passes. We have created a miserable system that is only good for rationing care. Doctors, who should be in control are help[less. Yes, there are abusers. Just don't let them in your MON and trust the doctors you have.”
By: Anonymous, 12/16/2014 06:12:59 am

“this means that the state medical, private insurances and the fed government r bearing the cost to treat the IW---while the ins companies pays Maximus--max monies to deny the treatment. If analyses, the Doc involved with the UR/IMR process, most r physical med rehab ones who in the bottom line for residency programs and their training is slightly better then physical therapist. They cannot make it in the real worlld an dso they do UR/IMR for money and know that keeping the ins company happy assures their job. What an abuse of human injured worker rights in USA in 2014---the basic concept of LC 4600 is out of the window. ”
By: Garry Crosby, 12/16/2014 02:12:09 pm
“This is a huge problem. When truly injured workers are denied insurer coverage for the medical care they need, they and their families often times end up on social service programs for survival. The taxpayer foots the bill. Sadly, conflicts of interest by Medical Review Officers on behalf of those who hire and pay them, has long been known to cause unreasonable denial of injured worker needed care. The extremely high percentage of those denied upon review reflects that the problem is not getting better. ”
By: Sharon Kramer, 12/16/2014 04:12:16 pm
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“Let's face it part of the guidelines appear to show that an injured worker in making progress. In many cases paliative treatments has gone on for years with little to no improvement or return to work. Why should employers pay for care that doesn't get someone back to work. Now if it gets them back to work that should be different and perhaps a carrier needs to really consider authorizing that care. However, most of the time the claimant doesn't get back to work. Take a look at what bogs down the system compound medications, and urine drug screens. All are presently being looked into as a means to fatten a doctors bottom line. Let's face it, what is the motivation of someone with a misserable job and a history of depression have to get back to work. Once they get into the system they get all this attention from doctors and other caregivers making them feel really important and fall into a victm mentality. These are the claimant's with the missing objective factors of disability. However, all claims are different but many fall into this pattern. IMR is just the result of a WCAB unwilling to say no and force case ahead.”
By: Julie A. Parkin, 12/22/2014 04:12:06 pm

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“Let's face it part of the guidelines appear to show that an injured worker in making progress. In many cases paliative treatments has gone on for years with little to no improvement or return to work. Why should employers pay for care that doesn't get someone back to work. Now if it gets them back to work that should be different and perhaps a carrier needs to really consider authorizing that care. However, most of the time the claimant doesn't get back to work. Take a look at what bogs down the system compound medications, and urine drug screens. All are presently being looked into as a means to fatten a doctors bottom line. Let's face it, what is the motivation of someone with a misserable job and a history of depression have to get back to work. Once they get into the system they get all this attention from doctors and other caregivers making them feel really important and fall into a victm mentality. These are the claimant's with the missing objective factors of disability. However, all claims are different but many fall into this pattern. IMR is just the result of a WCAB unwilling to say no and force case ahead.”
By: Julie A. Parkin, 12/22/2014 04:12:21 pm

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“Let's face it part of the guidelines appear to show that an injured worker in making progress. In many cases paliative treatments has gone on for years with little to no improvement or return to work. Why should employers pay for care that doesn't get someone back to work. Now if it gets them back to work that should be different and perhaps a carrier needs to really consider authorizing that care. However, most of the time the claimant doesn't get back to work. Take a look at what bogs down the system compound medications, and urine drug screens. All are presently being looked into as a means to fatten a doctors bottom line. Let's face it, what is the motivation of someone with a misserable job and a history of depression have to get back to work. Once they get into the system they get all this attention from doctors and other caregivers making them feel really important and fall into a victm mentality. These are the claimant's with the missing objective factors of disability. However, all claims are different but many fall into this pattern. IMR is just the result of a WCAB unwilling to say no and force case ahead.”
By: Julie A. Parkin, 12/22/2014 04:12:40 pm

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“Let's face it part of the guidelines appear to show that an injured worker in making progress. In many cases paliative treatments has gone on for years with little to no improvement or return to work. Why should employers pay for care that doesn't get someone back to work. Now if it gets them back to work that should be different and perhaps a carrier needs to really consider authorizing that care. However, most of the time the claimant doesn't get back to work. Take a look at what bogs down the system compound medications, and urine drug screens. All are presently being looked into as a means to fatten a doctors bottom line. Let's face it, what is the motivation of someone with a misserable job and a history of depression have to get back to work. Once they get into the system they get all this attention from doctors and other caregivers making them feel really important and fall into a victm mentality. These are the claimant's with the missing objective factors of disability. However, all claims are different but many fall into this pattern. IMR is just the result of a WCAB unwilling to say no and force case ahead.”
By: Julie A. Parkin, 12/22/2014 04:12:48 pm

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“I do wonder if they included the 2014 IMR's in this study, if things would have ben different. I have to say, some of the numbers did not add up to me either. 60 Minutes ran a story last Sunday about UR in issues of private insurance, with those who need psych treatment. I found it very eye opening and it does show the need for transparency and knowing the name of the reviewer. Some of the reviewers had a 100% denial rate on their reviews and were receiving $25 grand a month for doing these reviews. This could not be found without having their name disclosed on the review as we currently have with IMR. If they do not change this in our IMR system in which the name is identified, I am sure fraud and misuse will occur.”
By: Anonymous, 12/16/2014 05:12:58 pm

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“This article about IMR sheds light on the goals of the reform efforts over the last 10 years which has created a system that does exactly what it was designed to do; deny medical treatment and shift the cost to the taxpayer. Incrementally, the delivery of medical care to injured workers has been chipped away to its current state. With the introduction of utilization review in 2003 through SB 228, with additional utilization review and medical provider networks through SB 899 and now independent medical review through SB 863, the system is working perfectly to collect premiums from employers and deny care to injured workers while at the same time driving up costs and profits through cost-containment utilization review schemes. The cost of this denied care is shifted to the taxpayer, as these injured workers have nowhere else to turn to other than our emergency rooms and government-funded programs to obtain their care. Yes there is always the fraud argument with the recent investigations and scandals but the cost of these medical provider scandals collectively is pocket change compared to the money and profits generated in medical cost containment schemes. Every injured worker that has walked in my door with an IMR or utilization review denial in hand says the same thing, “How can an anonymous doctor who never sees me make my medical treatment decisions?” Everyone knows that there is something inherently wrong with this. Unfortunately for injured workers and taxpayers, this problem will have to get a lot worse before there is any political will to do anything about it. ”
By: Charles Cleveland, 12/16/2014 05:12:33 pm

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“How does this help get someone back to work?”
By: Jim Libien, 12/16/2014 06:12:44 pm

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“How does that help someone get back to work?”
By: Jim Libien, 12/16/2014 06:12:44 pm

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“The reason why the IMR determinations are concordant with the UR denials is in the details. The doctors for Maximus get $120 for each review. The money is not enough to spend appropriate time and come up with an adequate analysis of the case. Most practicing doctors have overhead and payroll. Maximus is taking all the profit from the system. Its much faster for the Maximus doctor to just agree and copy the determination of the UR doctor as oppose to quote other sections of the MTUS and explain why his opinion is different than the UR doctor. And so, the reason why most IMR determinations are replicas of the UR determination. If the UR denial is kept away from the Maximus doctor reviewing the case, the entire process would have been different. The Maximus doctors would not be able to just copy the UR determination. Recently Maximus has hired the same UR companies as independent contractors to do IMR. This coincides with the significantly faster turn around. Its obvious that the UR doctors will produce the same type of determinations as Maximus since its the same doctors. DWC seems to be an extension of the carriers under a mask. The entire system is mis-managed. For every dollar of treatment, they spend a dollar to deny treatment. Then reports surface that CA has the most expensive system. Stop sending every request to UR. Adjusters should authorize what makes sense. Try calling 5 different adjusters. The voice mail says to just fax authorization request directly to UR. Don't even sent it to the adjusters. They don't have time to look at them. That's not the way its suppose to work. If a request for Naprosyn is sent to UR and denied, it will go to IMR. UR cost about $200. IMR cost cost about $550. Process takes 3 months to complete. Cost of the Naprosyn $40. Cost of denial $750. Cost of a pissed off patient and doctor is unknown. Considering that 50% of IMR's are for meds, the system simply is illogical. ”
By: Dr. Edwin Haronian, 12/17/2014 05:12:29 am

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“The reason why the IMR determinations are concordant with the UR denials is in the details. The doctors for Maximus get $120 for each review. The money is not enough to spend appropriate time and come up with an adequate analysis of the case. Most practicing doctors have overhead and payroll. Maximus is taking all the profit from the system. Its much faster for the Maximus doctor to just agree and copy the determination of the UR doctor as oppose to quote other sections of the MTUS and explain why his opinion is different than the UR doctor. And so, the reason why most IMR determinations are replicas of the UR determination. If the UR denial is kept away from the Maximus doctor reviewing the case, the entire process would have been different. The Maximus doctors would not be able to just copy the UR determination. Recently Maximus has hired the same UR companies as independent contractors to do IMR. This coincides with the significantly faster turn around. Its obvious that the UR doctors will produce the same type of determinations as Maximus since its the same doctors. DWC seems to be an extension of the carriers under a mask. The entire system is mis-managed. For every dollar of treatment, they spend a dollar to deny treatment. Then reports surface that CA has the most expensive system. Stop sending every request to UR. Adjusters should authorize what makes sense. Try calling 5 different adjusters. The voice mail says to just fax authorization request directly to UR. Don't even sent it to the adjusters. They don't have time to look at them. That's not the way its suppose to work. If a request for Naprosyn is sent to UR and denied, it will go to IMR. UR cost about $200. IMR cost cost about $550. Process takes 3 months to complete. Cost of the Naprosyn $40. Cost of denial $750. Cost of a pissed off patient and doctor is unknown. Considering that 50% of IMR's are for meds, the system simply is illogical. ”
By: Dr. Edwin Haronian, 12/17/2014 05:12:57 am

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“Utilization Review for injured workers as currently practiced in California is abusive, harmful to patients, and discouraging for physicians thwarted from providing timely care even when a UR decision is sometimes overturned as per the story outlined on www.politicsofhealthcare.com, 12/16/14. That IMR upholds these UR denials 80% of the time is a travesty. Utilization Review and SB 863 should be reconsidered in the legislature in 2015. -- Robert L. Weinmann, MD, Editor”
By: Dr. Robert Weinmann, 12/17/2014 06:12:39 am

“If an injured worker is a Vet, let VA provide the medical treatment and bill the insurance carrier that is what I have done and currently am doing as the whole system on employer / carrier side is to fraud ridden in my humble opinion. ”
By: Kevin Toscano, 12/18/2014 12:12:55 am
“If an injured worker is a Vet, let VA provide the medical treatment and bill the insurance carrier that is what I have done and currently am doing as the whole system on employer / carrier side is to fraud ridden in my humble opinion. ”
By: Kevin Toscano, 12/18/2014 12:12:00 am
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“this is an incredible piece of information 4/5ths of the decisions are denials - so 80% of the time the requesting doctor is wrong - that is incredible - how could the doctors within the insurance company and employer's MPN be so bad at prescribing treatment. Are these doctors being trained? Do they have medical licenses? As a society isn't anyone concerned that these doctors are making 80 out of 100 requests WRONG! Does anyone in the administration think that this is outrageous!! These MPN doctors if they are wrong 80% of the time should have their licenses revoked. I wonder what their rate of accuracy in recommending medical treatment to non work comp patients is with health insurance carriers? ”
By: Keith More, Esq., 12/18/2014 08:12:19 pm

“Keth More, just because 85% of treatment requests are denied by IMR does not mean the PTP is wrong. I am an injured worker, and I can appeal most UR denials on my own. This takes time. If I am getting my UR denials overturned it shows the opposite, that what my doctor requested is accurate. My PTP was never sent my file, and does not have my records. They also do not get paid for reviewing 5 crate full of records every time they send a request. The doctor who was wrong was the UR doctor, not my PTP as I get the denials overturned. If a claims adjuster decides not to approve, and instead send to UR, they should be liable to send relevant records to the UR reviewer. That is not happening, and why the high rate of UR/IMR denials. It costs me $50. approx. in copies/faxes every time I appeal a UR denial. This is because my claims adjuster does not send relevant records to UR. If I did not do this, I would not get any medical treatment as most of my doctors requests are denied by UR. For the majority of CA IW's, many who do not have their medical records or knowledge to appeal, or doctor or attorney to help them...they are the 85% who are getting denied above. This system has been rigged this way. Until the state mandates claims adjusters must send relevant records to UR, and pays requesting doctors for their time to review guidelines and provide them for every request, injured workers who need and deserve treatment will be denied. Claims adjusters can also approve treatment requests. As written above most are not doing so. California injured workers are treated as cattle, with paper reviews deciding their fate,without relevant info to approve the request they get moved through the system. If they replaced QME/AME's with IMR to make medical decisions...shouldn't the IMR reviewer have the same records as the QME had, as well as time to review the records? ”
By: Anonymous, 12/29/2014 05:12:37 pm
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