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Tuesday, April 28, 2015

CWCI Backs up DWC Numbers on IMR Approval Rates, Geographic Distribution

  • State: California
  • Topic: WEST
  • - Popular with: Legal
  • -  0 shares
The California Workers' Compensation Institute has released a report on the way the independent …

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Rhonda Wofford Nov 3, 2016 a 2:58 pm PDT

Wow- a carrier-backed private research group used to promulgate propaganda as scientific research is found to support the "statistics" used to argue that IMR is a good thing! Such a surprise!

Barbara Ramiller Nov 3, 2016 a 2:58 pm PDT

Why are you surprised? If the data supports it wouldn't both studies draw the same conclusions since they are using the same data? It should make you feel more secure that the rational is correct since two sources have determined the outcome is accurate based on two reviews of the data.

John De Vasure Nov 3, 2016 a 2:58 pm PDT

The review could have provided more information on who files the most Applications requesting IMR's opinion. Last week I received four Notice of Assignment and Request for Information. All four of the injured workers and represented by an attorney. Three are treating with PM&R and one with an orthopedist, One request for a urine analysis, a request for acupuncture, another requesting 6 more chiropractic treatments and one for shoulder surgery. Labor code covers the acupuncture and chiropractic treatments. Monthly drug testing is not random when the injured worker is tested at every office visit. So, does that make it reasonable and necessary medical treatment?

Anonymous Nov 21, 2016 a 6:49 pm PST

They should not state who is requesting an IMR determination. This is a voluntary appeal process. Why is requesting an IMR by a doctor or attorney being turned into a bad thing, and something that needs to be tracked who is doing this? This is a legal appeal process for an injured worker or their advocate. I would like to see more data on how the 94% UR approval rate is determined. Monthly drug testing is a scam. Injured workers who are at these doctors offices have no choice, but to comply. I do not understand why an attorney or injured worker would appeal a UR denial for urine testing, unless it is included with another denial.

Anne Bazel Nov 3, 2016 a 2:58 pm PDT

The study proved that IMR works as intended. In most cases it acts exactly what insurance company-controlled legislators wanted...rubber stamp the UR denials. There's no need to waste time on judges. God forbid to actually provide care to an injured worker. We need to save money for impoverished insurance industry.

PG&E PG&E Nov 3, 2016 a 2:58 pm PDT

So when 94% of all UR decisions uphold and approve the requested treatment the "insurance controlled system" doesn't suck. But when 6% of the requested treatments that are not upheld by UR go to IMR and IMR upholds the underlying UR decision 91% of the time then the "insurance controlled system" sucks?

Kari Kushin Nov 3, 2016 a 2:58 pm PDT

So, from the article... 94% of ALL RFA's are APPROVED within 5 working days as per Labor Code. This means the Treating Physician followed MTUS Guidelines for treatment and the Injured Worker received appropriate treatment. It would be interesting to know which of the Physicians and Applicant Attorney's are involved in the other 6% of RFA's which are denied and IMR eligible. Remember, the DEFENSE has to pay for ALL the UR reviews AND the IMR Fees. Would there even be 6% denied if the Applicant Attorney's had to pay to have a little skin in the game???

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

Just had IMR deny acupuncture since the PTP had not stated how the initial acupuncture sessions had improved function. Hard to do when these initial sessions are denied!

4616 says that IMR must be completed within 30 days of receipt of needed records - late IMR is invalid IMR.

Anonymous Nov 21, 2016 a 6:49 pm PST

Why is it every doctor, applicant attorney and injured worker I have discussed UR with are stating opposite from this report, that most requests are denied by UR and not approved by UR?

I would think applicant attorney's who are copied on IMR determinations would know if 95% of their clients UR determinations coming in their office is approved. Is this occurring applicant attorney's ? Treating doctors are you receiving a 95% UR approval rate for your request? Dr Weinmann what say you? UR doctors reading this who are doing UR reviews, are you approving 95% of the UR requests? Claims adjusters, do you see a 95% approval rate on UR determinations? I would like some honest input on this because this is complete opposite from what I have seen in this system. If this is the case could someone please leave a list of doctors who are getting a 95% approval rate from UR?

I do not view the high numbers of requests for IMR reviews by applicant attorney's as a negative. It is their right and they are advocating for treatment for their clients. I know of a handful of applicant attorney's who are working extremely hard to get UR denials overturned and IMR approved. Due to how much time is involved to do a successful appeal, these attorney's may be the exception and not the rule.

Eugene Forcier Nov 3, 2016 a 2:58 pm PDT

Hi, I am an Examiner/Adjuster. Almost all medical request for service (RFA's) are approved on my desk and the other Adjuster's desks as well. I am lucky in that I can approve some RFA's without the UR process. Most of my Injured Workers are not represented so no Attorney sees the approved or denied RFA's. The system is set up so that I pay for All the Utilization Reviews, for All the IMR's and for All the Maximus' fees to process the IMR's through their various stages. I believe some Applicant Attorney's just file the IMR's because they know the Defense has to follow the strict time guidelines and the Defense has to pay for Everything (I have had IMR's filed for prescription medications where the physician requested 30 pills and UR approved, per MTUS, 20 pills). Some Applicant Attorney's are also trying to push the RFA's back to the WCAB Judge's as they are not trained medical professionals and can be persuaded by the Attorney and cost the Defense money in litigation costs. Yes, I do see a 95% approval to RFA's. Most of them you will never hear about as they are going to MPN and Industrial Clinic physicians. Most of the RFA Denials I have personally seen are mainly because the Physician is treating outside of the MTUS Guidelines and they refuse to participate in the Peer-to-Peer review required by UR prior to Denying the RFA.

Anonymous Nov 21, 2016 a 6:49 pm PST

Adjuster I believe you and the company you work for is doing something right and why most of your injured workers do not need to hire attorney's. I see opposite most requests are denied, and these are doctors inside of the MPN. I see opposite that the request is within the guidelines but the UR doctor is using guidelines incorrectly as a means to deny. I have overturned most of the denials myself as an injured worker and would never play UR games as mentioned to cost the company money. Most of the injured workers I have contact with are having most of their doctors requests denied by UR and IMR. They are treating inside of MPN.

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