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Wednesday, February 11, 2015

Maximus Projects 144,000 IMR Applications and Decisions per Year

  • By Greg Jones
  • State: California
  • Topic: Top
  • - Popular with: Legal
  • -  0 shares
LOS ANGELES – Maximus Federal Services, armed with data from the past two years of serving as …

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6 Comments (9 Replies)

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John A. Don esq. Nov 3, 2016 a 2:58 pm PDT

MY client is 58 - she's had about seven back surgeries. She can't sleep because UR denied her tramazepan. UR has denied her pain medicine and home care. Her daughter is missing work to keep her mom from jumping out a window - not exaggerating. Sure, the numbers look great. Medical costs are being cut left & right - but - the workers' dignity and ability to survive is being thrown in the toilet. California deserves better than a ghost doctor system that can callously deny essential care.

Anonymous Nov 21, 2016 a 6:49 pm PST

So sorry to read about your client. I hope your clients doctor is re-requesting this and checking off the box under "change of condition". When they abruptly cut off a patient medication they will usually have a change of condition. Hopefully your clients PTP will know how to request this and show proper guidelines to get this approved on the second time. I agree that California injured workers deserve better than this.

Anonymous Nov 3, 2016 a 2:58 pm PDT

Sorry about the situation. First, I would question why anyone would necessitate 7 surgeries in the spine. Without records, I have to assume she is in care of bad surgeons. I've seen some of the surgery jobs in WC and it varies widely in quality. As far as not being able to get the meds, I really need to blame the provider again. MTUS is quite straight forward when it comes to meds. Either the requester is too lazy to read the MTUS or has very poor documentation. I just did an IMR the other day which contained several narrative progress report from a requester which just has 3 sentences regarding inspection portion of the physical examination. For example, following is verbatim of the report. "There's no sign of sedation. She is alrt and oriented. She is using a cane for ambulation." That was the entirety of the physical examination. This particular one was request for chiropractic treatment. Her's the subjective portion since there's really nothing to go by in objective. "She finished chiropractic treatment which has helped her with her back pain. Overall, she reports no changes in overall health and continues to be limited with the above complaints as a result of her activities of daily living." That's it. Does it sound like the patient had functional improvement? She's better with chiropractic care but overall remains unchanged? What kind of garbage assessment is that? You know what's even funnier? Request was and is for neck and low back. The chiropractic note revealed chiropractor never even looked at the low back for entire 12 visit regimen. This is the kind of garbage assessment and treatment that comes through the process. What I'd advise you is if you really cared about patient's well being and not your bottom line which is linked to settlement amount, you would've gotten her a new doctor. So this is entire fault of you and the doctor you work with. Don't blame the system.

Anonymous Nov 3, 2016 a 2:58 pm PDT

Yes it hurts everyone when state uses reform that effects everyone instead of taking those surgeons who perform 7 back surgeries out of system. But you contributed by continuing to use those bad doctors. We should get rid of all the bad attorneys like you, all the bad doctors like your client's surgeon and overhaul the entire system. All these patch works just hurts the innocent parties and unscrupulous pro like you and the doctors you are associated with find new loophole to take advantage of.

Charles Cleveland Nov 3, 2016 a 2:58 pm PDT

12,000 IMR applications a month. If those numbers don't scream that something is wrong with utilization review and that both utilization review and IMR are a moneymaking scam to the people in government who are supposed to be regulating this then idiocracy as truly begun. The cost containment scam goes off at about a half $1 billion a year, this makes the bogus pharmaceutical creams and fake spinal hardware scams look like pocket change.

Anonymous Nov 3, 2016 a 2:58 pm PDT

Actually, that's just one sided argument. IMR gets a lot of cases because it's free and there's nothing to lose for the applicant side. Look at IBR where providers have to ante up for the process. Even though it guarantees the refund in case of any recovery and there's very high number of over turn, not too many go through the process.

Eric Schmutz Nov 3, 2016 a 2:58 pm PDT

If anyone is injured on the job, and the carrier avoid treatment through UR and IMR, then the best advice an applicant attorney can give the applicant is to treat OUTSIDE

Eric Schmutz Nov 3, 2016 a 2:58 pm PDT

If someone is injured on the job, and the carrier avoids treatment through UR and IMR, then the best advice the attorney can give the applicant is to seek treatment OUTSIDE of the system established to protect injured employees in California.

Anonymous Nov 3, 2016 a 2:58 pm PDT

And I bet you specialize in treating these denied cases clogging up the system with all your lien filings.

Dr. Robert Weinmann Nov 3, 2016 a 2:58 pm PDT

As long as wrongful decisions by Utilization Review (UR) physicians are allowed to be upheld by anonymous Independent Medical Review (IMR) surrogates, injured workers will continue to be deprived of indicated and necessary medical and surgical attention. Since the IMR surrogate is allowed to remain anonymous, there's no way to be sure that an IMR physician actually reviewed the UR decision. In one case our office got a denial while the supporting information we were sending was still in our fax machine. The cure is to require UR and IMR doctors to be licensed in the states in which their decisions are rendered and to take away the protection of anonymity.

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

Anonymous Nov 21, 2016 a 6:49 pm PST

I agree with Dr Weinmann. If there is any doubt about what is going on, I suggest taking an hour of your day and read some of the IMR determinations on the states web page. They are often times using MTUS guidelines incorrectly to do blanket denials. I want some transparency with IMR reviewers. Someone needs to present legislation this year that will take away the anonymity of the IMR reviewer.

Anonymous Nov 3, 2016 a 2:58 pm PDT

For every IMR that gets overturned it shows a UR doctor got it wrong, the fix should start with UR, maybe then there won’t be as many IMR’s. I have had a few IMR’s that overturned a UR denial and those UR denials happened because the UR reviewer failed to read the records supplied to them.

Anonymous Nov 3, 2016 a 2:58 pm PDT

To me, all these UR/IMR denials is the state, the insurer, and UR/ IMR saying doctors who treat injured workers are stupid, these same doctors when treating non injured workers don’t look so stupid when it’s private health care and UR’s, in my opinion it’s the makers of regulations that are the stupid ones for not being able to see what’s going on here.

JAMES BADER Nov 3, 2016 a 2:58 pm PDT

Then workers compensation system has lost its purpose, to deliver benefits to injured workers without unreasonable delay. The workers who have accepted claim, and are treating within the MPN cannot received medical treatment in a timely fashion. They cant have their disputes for medical treatment heard by a judge, just some unknown person (hopefully a doctor) who doesn't examine the patient, rarely sees the pertinent medical records, and causes delay in medical treatment which causes the need for medical treatment to be moot anyway. Where are the politicians who are going to step up and bring justice back for the little guy, the employee against the juggernaut of the insurance carriers, the UR physicians, and the IMR physicians. Is there anyone who realizes the current system clearly defeats the entire purpose of workers compensation ?

Anonymous Nov 3, 2016 a 2:58 pm PDT

actually, WC doctors are stupid barring few exceptions. UR is not new to the physicians. In fact UR was copied from managed care model. So it existed for years before WC decided to implement it. It's only WC doctors who complain. Actually, a lot of WC doctors still don't know what an IMR or MTUS is. They don't bother to read. So they are stupid... and lazy. The way I see it, comp UR process is actually much easier. MTUS is quite clear. In private pay setting, every insurance companies have their own policy as to what's experimental and which guideline to accept. So WC is much easier to deal with. Then why so much complaint? It's simple. WC doctors are lazy and stupid. It's partly system's fault. Because through each reform, they put good guys out of business and only mills that can treat by the volume survived to see the light of day. So we have comp mills only these days. Doctors continue to be ignorant of changes because they can write off the denials and make money receiving pennies on the dollar because they just have high volume with minimal overhead. It's a number game. The way I see it, they really need to start cracking down on these unscrupulous providers and overhaul the whole system. Look at that first comment. 7 back surgeries. Somebody would've been sued if it wasn't WC case.

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