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Monday, March 16, 2015

Maximus Could Be the Cause of Missing IMR Records

  • By Greg Jones
  • State: California
  • Topic: Top
  • - Popular with: Legal
  • -  1 share
The 5,000 independent medical-review cases Maximus Federal Services says are missing medical records…

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11 Comments (4 Replies)

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Anonymous Nov 3, 2016 a 7:58 am PDT

Isn't it time topull the plug on IMR? It has been a disaster and not likely to improve.

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

If you are in the mpn then there should be no ur!

Lisa Italia Nov 3, 2016 a 7:58 am PDT

And replace it with what? The old way was expensive litigation and decisions by non-medical judges. It's easy to tear something down, harder to build something better. And yet that is what needs to happen if we are to take better care of injured workers and keep costs manageable.

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

"Drastic improvements in solving medical disputes"? - to have a ghost doctor deny care to California workers without even doing a medical exam? Really?

Mary Huckabaa Nov 3, 2016 a 7:58 am PDT

Consider the reason that no penalties have been assessed is that MAXIMUS is the one causing the delays. This has been from the start, they were months and months behind. Yet, they were awarded a new contract!!! THAT is shameful. THAT is when DWC could have taken action. Written into the contract that if the IMR decision is late, they don't get paid!!!! And, if more than 10% are late, the contract can be cancelled!!!!

However, we are stuck with MAXIMUS. So....

YES there is a bar coded cover sheet.

YES there are records missed, at times, by carriers.

YES the applicant or a/a can submit any records that didn't go to UR, to the IMR so that all relevant records are there if there is an issue.

YES there are significant documented occurrences of the records being submitted by carriers, with the bar coded cover sheets, and MAXIMUS says they didn't get them. When given the proof of mailing, they suddenly find them.

If we all work together from the start, instead of being adversarial, the system could work.

If the PTP submitted the RFA with the actual reference to the MTUS that would support the request, and the records, the URO would be hard pressed to deny. Thus no IMR required. This happens about 76% of the time.

If the UR does deny, don't just submit the same stuff to IMR, submit the reference to MTUS and supporting records/reports/testing that support the request. You'll get your overturn. This happens about 16% of the time.

This leaves the remaining 8% as lawfully denied requests for treatment. The great majority of these are prescriptions, often abused. These are, of course, subject to petition appealing the IMR decision.

In those cases, a new UR can be sent if the patient's condition changes, new information is found, or one year has passed.

It is workable, if we work with it instead of against it.


Anonymous Nov 3, 2016 a 7:58 am PDT

Soothsayer is exactly right. Unfortunately that is a logical decision and I have not met or even heard of anyone at DIR or DWC that has the ability to use logic. The folks in charge now are just the yes men / women and the enforcers for a few large self insureds and a few of them have connections to the old SCIF regime. They have an agenda that has been put in place and they will stop at nothing to forward that agenda. I am sure they are analyzing everything that IMR overturns as well, and trying to influence that behind closed doors. Dirty Scoundrels.

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

hrtr we go with the Blame Game.In short, the Claims Adm and the DWC r blameless, but the medical providers/Maximus r at fault. Pointing fingers is not good, as u point the index finger to some one else, ur 3 fingers point to u. The UR/IMR should be totally independent off the ins company influence and should get paid from a common fund to be non biased. The end point is that the IW gets no treatment or benefits but in depositions, the IW is portrayed as an intelligent,educated person and is also an expert in med/legal matters.

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

Anyone who actually works with IMR knows that Maximus has a bar code cover sheet that is required to be on top of the records so that they are matched to the correct file. Why not provide for an IMR appeal if ur is upheld where the WCJ is a trial de novo and the remedy is that the treatment can be ordered not just another IMR? Why not lift the td cap when treatment found necessary has been delayed ?

WILLIAM YATTAW Nov 3, 2016 a 7:58 am PDT

It would appear that we have an applicant attorney in the group. Obviously the administrator would never vote to increase TD.

WILLIAM YATTAW Nov 3, 2016 a 7:58 am PDT

The operative word here is "Could" not is. So is Maximus at fault who knows for sure?

D C Nov 3, 2016 a 7:58 am PDT

I know of some instances records were not sent to MAXIMUS by the claims adjuster as the injured workers stated they were not copied with records sent to MAXIMUS on another forum. I do not know how common this is. It sounds like both MAXIMUS and some claims adjusters are to blame.

Also, the number of cases that records were not sent decreased after the proposed fine. So there were some adjusters who were not sending records previously.

In my case my claims adjuster is not sending relevant records to IMR, the few times I have had an IMR. I have had IMR determinations but they should have been cancelled but the adjuster failed to inform MAXIMUS the UR was appealed/overturned. So the UR approved my doctors request during a UR internal appeal due to my appeal and the relevant records I sent directly to UR. My claims adjuster did not send any records to UR that were listed and sent records to IMR which were not relevant to the requested treatment. This caused IMR to deny the request and UR appeal to approve it.

This shows me that if relevant records are not sent to IMR then the request will be denied. If an injured worker has a claims adjuster like I have, they will have a difficult time getting treatment.

There is no recourse that I know of if a claims adjuster sends records, but not relevant records that show the request is warranted. I hope I have the only evil claims adjuster out there and this problem is not wide spread.

Anonymous Nov 3, 2016 a 7:58 am PDT

I hope you guys are talking about real referrals for real ACOEM recommend treatments. This compound stuff, and silly referrals to doctors that pump out boilerplate reports, just to milk the system is laughable and damaging the integrity of the medical establishment.

Rhonda Wofford Nov 3, 2016 a 7:58 am PDT

We shouldn't allow the exceptions to dilute the message. If we do; then we risk allowing the IW, and their receipt of timely and appropriate medical care, to be lost as the focus of the system. The fundamental truths remain unchanged, IW's are not getting treated adequately to make them whole, and the providers aren't get paid properly for treating them, and the administrative remedies that are purportedly designed to ensure that both are occurring, don't work. We cannot be surprised by this outcome when the individuals who put UR/IMR/IBR in place did so under the cover of darkness and secrecy. We know that the same inappropriate influence is exerted at the DWC and the Office of the Sec. of Labor. One just has to look at the DWC's failure to punish adjusters when they have admitted that they know of bad actors; in contrast to, their jubilation when they report how many lien claimants they have sanctioned, to know where their loyalties lie. And the Sec. of Labor, keeps talking about how IMR is better than litigation. For whom??? Certainly not for the Injured Worker!

Dr. Edwin Haronian Nov 3, 2016 a 7:58 am PDT

Try calling and adjuster. 90% no one picks up the phone and there is no response. Leave a message! There is no one home! Everything is automated. The denials are automated. Bill review is automated. Record copies are automated. Anything that requires attention will not take place. Automated messages say submit authorization request directly to UR. Basically the adjuster is out of the loop on everything related to the case. Except sending out objections of course. Oh, yes, even that is automated!

The adjusters and the carriers have the DWC and the politicians in their hand. Totally biased system in favor of the carriers that are rushing to CA to take a bite of the cake. Reserves going high by providing the minimum treatment and denials are easy since there is no other recourse after a denial. There is no penalty to deny or delay anything and everything.

Dr. Edwin Haronian Nov 3, 2016 a 7:58 am PDT

Try calling and adjuster. 90% no one picks up the phone and there is no response. Leave a message! There is no one home! Everything is automated. The denials are automated. Bill review is automated. Record copies are automated. Anything that requires attention will not take place. Automated messages say submit authorization request directly to UR. Basically the adjuster is out of the loop on everything related to the case. Except sending out objections of course. Oh, yes, even that is automated!

The adjusters and the carriers have the DWC and the politicians in their hand. Totally biased system in favor of the carriers that are rushing to CA to take a bite of the cake. Reserves going high by providing the minimum treatment and denials are easy since there is no other recourse after a denial. There is no penalty to deny or delay anything and everything.

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