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Monday, March 23, 2015

CWCI: Small Number of Docs Account for most IMR Decisions, MPN Savings in Question

  • By Greg Jones
  • State: California
  • Topic: Top
  • - Popular with: Insurance
  • -  0 shares
Nearly half of the 138,000 independent medical-review decision letters issued in 2014 were the resul…

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14 Comments (10 Replies)

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Anonymous Nov 3, 2016 a 7:58 am PDT

So let's see. 91% same few IMR reviewers. No wonder the delay
If most treatments are authorized, then we don't need them. If UR and IMR findings are similar, we don't need IMR
If southern Ca is the highest, could it be that there are more patients here.
Or, if the represented cases have the highest frequency, eliminate attorneys ( just kidding)
Overall. looking at this analysis, IMR is a flop and Maximus is ripping the carriers off and delaying treatment.
What is interesting is how CWCI knows who is deciding these cases, and we aren't allowed to know.

Barbara Ramiller Nov 3, 2016 a 7:58 am PDT

Anybody can get the data it is posted on the DWC website. CWCI just took the time to put the data on a spreadsheet and review the information.

Anonymous Nov 3, 2016 a 7:58 am PDT

I bet a lot of the treatment ordered is bull shit. Ordered over and over again. I feel bad for the patients with denied claims that have endless appointments for treatment that would never have been ordered in 1985.

Anonymous Nov 3, 2016 a 7:58 am PDT

I bet a lot of the treatment ordered is bull shit. Ordered over and over again. I feel bad for the patients with denied claims that have endless appointments for treatment that would never have been ordered in 1985.

Anonymous Nov 3, 2016 a 7:58 am PDT

From my own personal experience it did not matter what PTP I went to. Most treatment requests of mine were denied by UR and then overturned.

I have had an ortho surgeon as PTP with most patients work comp and 20 patients sitting in his waiting room at a time, like a mill. I switched to a Neurosurgeon who does very little work comp. Did not know what an RFA form was and his requests get denied by UR. I have also been to a pain management doctor who has small amount of work comp patients. I have not seen any difference in the doctors I see vs UR denials.

Applicant attorneys should know if this article is reflective of the real world. Is it? But then again most patients recover from work related injuries and only a certain number are chronically in this system.

xavier zendejas Nov 3, 2016 a 7:58 am PDT

This blows the argument that insurance denies everything, this proves that the problem is over treatment and we know who over treats.

Anonymous Nov 3, 2016 a 7:58 am PDT

There's one problem with this report. It doesn't give complete picture. Yes it is revealing that there are some unscrupulous treaters in LA area who don't know what they are doing and just clog up the system. These guys are the same guys who file majority of the liens in the state. They are extremely applicant oriented and they should be the target for reform, not the entire system. And yet, they are the one's utilizing the IMR the most. Most treaters do not have the capability to deal with extra admin for IMR. So... what's missing here????

The data from Maximus. Just how many reviewers are issuing these 12,000 cases/month? They started out with 200 and now added 500-700 more since last summer. So are they utilizing these reviewers evenly? They have high volume reviewers who perform dozens of cases per day. There are reviewers who perform a hundred cases a day even. That's 1/6 of the entire volume by one guy. So in reality, all these hundreds of panel docs are for a show. Bulk of the reviews are done by just a few docs. And these docs are supposedly full time practicing. So where do they find time to do all the reviews? Each review, if done properly should take at least an hour each with all the records to review and multiple requests. How do these physicians who perform dozens of reviews/day do it while running a full time practice? Perhaps, he's rubber stamping the reports and the non-physicians are performing the reviews to mass generate the reports. So most of the reviews are not performed by the physicians, but mid-level or people trained off the street which would be in violation of the labor code. And Maximus allowing this is majorly breaking the law. Time to investigate Maximus... Where are the applicant attorneys?

Anonymous Nov 3, 2016 a 7:58 am PDT

Workdoc: read the article again. CWCI doesn't know the names of the IMR reviewers. 91% refers to the providers being reviewed. There's a small portion of providers causing the IMR reviews. And the statistics on Los Angeles take into consideration the number of claims these are percentages.

Anonymous Nov 3, 2016 a 7:58 am PDT

Good Work, Spin Doctors. IMR is a joke it's just a rubber stamp influenced by the corrupt DIR

Garry Crosby Nov 3, 2016 a 7:58 am PDT

this now reached the usual practice esp in governments, that is spinning the wheel. Based on these numbers, it is the providers who r at fault, The DWC,INS company and Maximus r doing their jobs. But the most important part of this discussion has been ignored. Treatment to an injured worker is denied and the powers to be r deflecting from that subject. Also to state that UR/IMR prevent harm to the IW, what does the denial do? worse disability and most IWs r permanently disabled and go on social security disability, shifting the burden to the fed gov which means the ins companies r scott free and u and I pay from our taxes. I propose that LC 4600 be eliminated and there should be no W/C coverage in CA and if u get hurt on the job, u r responsible for treatment with private ins, medical, medicaid or medicare!!!!!!!! this will eliminate UR/IMR and all the rich ins companies!!!!!!! from plying their ware in CA

John De Vasure Nov 3, 2016 a 7:58 am PDT

I work in a claims office in central California. We get about an average of 5 requests per week from Maximus for information. Most of the Applications for Review we receive were not filed by the primary treating physician. They were filed by a person educated in the medical field. The Request gets reviewed and guess who pays?

Gilbert Fisher Nov 3, 2016 a 7:58 am PDT

Among the carrier MPN docs, there are about 25%, who are defense-oriented docs, who don't RFA anything the adjuster won't approve, and in turn, the adjuster approves most of what they ask. They wouldn't do an IMR appeal, as they are afraid of offending their primary referral source, which is the IC. Then there is another 65% of doctors (or so) that are in the MPN, but really don't understand comp or how to write a report, and sometimes don't even take work comp cases, and they certainly won't or don't know how to do an IMR appeal. And finally, there are about 10% of doctors who are somewhat more applicant-oriented, and willing to ask for things. The adjusters don't really like these doctors and UR everything they ask for. That is why they are responsible for most of the IMR requests. Then you have IMR docs, who are deluged with requests, and they find that they can simply uphold the denial, and parrot the reasoning in the UR denial, a lot faster than they can actually read the medicals and come up with a reason to overturn, and they get paid by the number of decisions they render, right? So guess what, they deny all day. What would be nice is if we had a system that provided the same level of care to work comp patients as to those in private group health.

Janet Phinick Nov 3, 2016 a 7:58 am PDT

Yes, Integrated Health Care is a solution. Getting it to work will take some effort. We need a forum on that topic alone. It keeps coming up on other forum pages, so why doesn't WC Central just get it out there and engage the conversation?

Anonymous Nov 3, 2016 a 7:58 am PDT

In the group health system IMR is the final decision on any disputed care. There are many studies that show group health provides less care for the soft tissue injuries that are so predominant in work comp.

Anonymous Nov 21, 2016 a 10:49 am PST

In group health IMR is absolutely not the only avenue to get a decision changed in group health. Each company has an appeal process. A doctor can often times get the denial overturned with a phone call. With things like denials for clinical trials, this becomes more difficult and REAL patient advocates can also intervene in these group health situations. There are problems with group health. They are not perfect either.I do agree that studies show group health provides less spinal fusions.

Herbert Alschuler Nov 3, 2016 a 7:58 am PDT

The problem is that treatment to cure is defined as treatment under the MTUS.

Christopher Lear Nov 3, 2016 a 7:58 am PDT

And what solution would you suggest that would not provide a blank check to the doctor?

John A. Don esq. Nov 3, 2016 a 7:58 am PDT

So far this is the best argument in favor of IMR: If Michael Jackson had IMR - he'd still be alive! IMR could have saved Jimmie Hendricks and Janis Joplin as well. The Doors would still be touring if we only had IMR a few decades back! I would not be typing this if IMR had been around before - I'd be heading to ticket masters to get my Nirvana ticks....

Anonymous Nov 3, 2016 a 7:58 am PDT

Too funny!!! I like your approach.

Anonymous Nov 3, 2016 a 7:58 am PDT

These numbers appear misleading. I have asked this question before, but cannot get a response. Are they counting EVERY medication they prescribe in these statistics? If they are this does reflect that most medications get approved but many treatments and testing may not. Also, once they deny a medication the patient has to wait 12 months before requesting it again.

I wish we could see a breakdown of what is getting approved vs denied because many injured workers get denied treatment, testing's, PT etc. I really have no idea.

I also wonder if insurance companies are targeting certain providers and just denying their patients, like the ten's unit scandal where an insurance company was denying a certain company unilaterally.

If you do read the IMR determinations you can see they are using same boilerplate reasoning to deny most things. Certain things have a 100% IMR denial rate.

Anonymous Nov 3, 2016 a 7:58 am PDT

Anonymous Nov 3, 2016 a 7:58 am PDT

One case could contain multiple requests. They are counting by the cases.

Anonymous Nov 21, 2016 a 10:49 am PST

Thank you, insider.

Barbara Ramiller Nov 3, 2016 a 7:58 am PDT

you can go on the state's website and see every single IMR outcome. They are published with the injured worker's names blocked out. You can see the treatment that is being requested and denied.

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