Maximus Says Scrap UR, Go Straight to IMR for Disputed Drug Denials

By Elaine Goodman
National
Topic: Top
- Popular with: Legal
- 3 shares

The development of a model law for states seeking to adopt a workers’ comp drug formulary has …

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4 Comments (2 Replies)

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John Don Aug 27, 2019 a 10:08 am PDT

What a great idea! This way we can have 90% denial rate from the get go & the workers can all go on MEDI-CAL.

Randy Bugg Aug 27, 2019 a 10:08 am PDT

I see some potential issues in regard to CA. Adjusters cannot "deny" medications or any medical treatment for that matter. Only the UR process may non-certify. So, in order for their to be a "denial" of medications to go "straight to IMR" one would be obliged to do so via UR in our great state due to the current statutory framework.

Also, if the UR process was working within the ideal context of the current statutes (and we all know it often does not) that process would afford a peer to peer telephone conversation to discuss the medications and its use, prior to any non-certification. Since IMR does not allow for any communication with the reviewer, the concept of IMR as the only avenue of appealing would not be very attractive if I were an injured worker

Randy Bugg Aug 27, 2019 a 10:08 am PDT

Apologies for incorrect use of "their". I was typing quickly...

Beth Harville Sep 5, 2019 a 3:09 pm PDT

That was my take also -- the adjusters can't say no; a request needs to go to UR in order for that to happen. If that was changed so UR was side-stepped on prescriptions and everything went to Maximus instead, they would be able to charge the IMR fee for every RFA that wasn't obviously approved within the formulary. This mostly sounds like a way for Maximus to generate more income.

Dr Aug 27, 2019 a 2:08 pm PDT

The letter from Maximus to NCOIL recommends that the "right to appeal the independent review organization's decision should be limited." This limited right would be "in the interest of finality."Yessir, it looks like independent review has discovered still another way to shortchange injured workers.

An appeal "might be allowed if it's found that the reviewer had a conflict of interest, a hurdle purposefully made too high even for the most reasonable of appeals especially if the IMR doctor is allowed to remain "anonymous."

Robert L. Weinmann, MD, editor. www.politicsofhealthcare.com