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Anonymous Nov 3, 2016 a 7:58 am PDT

Who cares what they review or not review. They are going to deny the requested treatment anyway. Our system is in the toilet

Manila Manila Nov 3, 2016 a 7:58 am PDT

The problem with IMR is their dogged reflexive adherence to ODG, MTUS and ACOEM guides - even when presented with abundant evidence and a rationale why a variance is needed. IMR doctors might as well be robots since they act as if "guidelines" from the above publications are "rules" that can never be violated. Years Kaiser handcuffed many of its doctors with mandated treatment protocols despite having physicians from Stanford, UC and other prestigious schools. Ultimately Kaiser got itself into trouble for withholding care unreasonably and they loosened up their bureaucratic stranglehold on their doctors so now more make independent decisions about medical care (although many remain handcuffed out of fear of censure and job loss). The point is, I when IMR is presented with a good evidence and a rationale for treatment outside of the guidelines, they should recognize that a one size fits all approach is not proper practice of medicine and IMR doctors should have the courage to approve something apart from their holy "guides."

Richard Moser Nov 3, 2016 a 7:58 am PDT

Absolutely.

Pete Thomas Nov 3, 2016 a 7:58 am PDT

I just had yet another case of successfully Appealing (through internal processes) a UR denial and getting the treatment certified for my patient, but in the meantime the AA had sent the initial denial to IMR. The IMR decision was to UPHOLD the initial denial and disregarded the subsequent certification. My presumption is that many AAs have their office staff trained to automatically send ALL UR denials to IMR. This included menial issues where a request had been modified (such as medication request being certified but the request for refill being modified (or not agreed upon) pending response over the ensuing month, which is not unreasonable. The IW posting above who appeals the denials should be applauded and he/she is probably one in 1000 that does so. Also, the vast majority of treating docs do not internally appeal most UR denials (unless it is a big money-making procedure). IF more treating docs would go through the internal Appeal and IF the AA would wait for the response to the appeal, much of the robotic IMR process would not even be necessary. In addition, more UR docs need to actually use their brains and consider the individual case at hand in decision making, rather than going through a cook book Guideline, which by definition is NOT an irrevocable mandate! At times following the Guidelines step by step rather than looking at the specific case of the patient being reviewed, results in UR decisions that would be otherwise be tantamount to malpractice had the UR doc been a treating physicians. Just saying...

Anonymous Nov 21, 2016 a 10:49 am PST

Your UR approval (by internal UR appeal process) stands even though IMR denied it after. I hope you are not having any issues with this. Many applicant attorney's are sending every request through UR. If it has been overturned by UR internal appeals process the claims adjuster or applicant attorney can stop the IMR ( but I am not seeing them do this, maybe they are not aware they can)as long as it has not gotten to the point where records were forwarded from IMR company to IMR doctor. After this point the IMR cannot be stopped. Regardless of the IMR outcome your UR approval stands. I do not know if your office is copied when an applicant attorney sends in the IMR, if you are perhaps a staff member can contact the AA office and ask them to cancel the IMR once you receive the UR approval. I agree with you that AA should wait on UR appeal but CAAA teaches their AA's to send immediately to avoid deadlines. (watching their podcast class on SB863) You should be applauded as well for doing internal UR appeals for your patients. You are also one in 1000, other than those who appeal big things like surgery. I place no blame on those doctors because I am very well aware of the time it takes to appeal these, and they do not to my knowledge get paid for their time to do so. I agree with you on your comments about these guidelines.

Pete Thomas Nov 3, 2016 a 7:58 am PDT

IW, I think we have had this issue come up before on a different post. I agree with you that the UR approval SHOULD stand; BUT, it requires yet more time spent, more letter writing, and contacting the adjustor to make sure he/she does not automatically abide by the IMR decision. In the meantime, the requested treatment remains denied "per IMR" and the injured worker suffers the repercussions. In the latest case, I did contact the AA as soon the IMR application letter came in, but by the time AA sent a letter asking to retract the IMR based on a certified appeal, the IMR decision had already been issued! It is just tons of extra work on the part of the doc that is never required in an HMO or PPO system.

David Stein Nov 3, 2016 a 7:58 am PDT

I also know several people in the departments of insurance companies and trust me when I tell you that they will also be prosecuted.

Anonymous Nov 21, 2016 a 10:49 am PST

Your UR approval (by internal UR appeal process) stands even though IMR denied it after. I hope you are not having any issues with this. Many applicant attorney's are sending every request through UR. If it has been overturned by UR internal appeals process the claims adjuster or applicant attorney can stop the IMR ( but I am not seeing them do this, maybe they are not aware they can)as long as it has not gotten to the point where records were forwarded from IMR company to IMR doctor. After this point the IMR cannot be stopped. Regardless of the IMR outcome your UR approval stands. I do not know if your office is copied when an applicant attorney sends in the IMR, if you are perhaps a staff member can contact the AA office and ask them to cancel the IMR once you receive the UR approval. I agree with you that AA should wait on UR appeal but CAAA teaches their AA's to send immediately to avoid deadlines. (watching their podcast class on SB863) You should be applauded as well for doing internal UR appeals for your patients. You are also one in 1000, other than those who appeal big things like surgery. I place no blame on those doctors because I am very well aware of the time it takes to appeal these, and they do not to my knowledge get paid for their time to do so. I agree with you on your comments about these guidelines.

Pete Thomas Nov 3, 2016 a 7:58 am PDT

IW, I think we have had this issue come up before on a different post. I agree with you that the UR approval SHOULD stand; BUT, it requires yet more time spent, more letter writing, and contacting the adjustor to make sure he/she does not automatically abide by the IMR decision. In the meantime, the requested treatment remains denied "per IMR" and the injured worker suffers the repercussions. In the latest case, I did contact the AA as soon the IMR application letter came in, but by the time AA sent a letter asking to retract the IMR based on a certified appeal, the IMR decision had already been issued! It is just tons of extra work on the part of the doc that is never required in an HMO or PPO system.

Rodolfo Garcia Nov 3, 2016 a 7:58 am PDT

what is imr?

Anonymous Nov 21, 2016 a 10:49 am PST

Your UR approval (by internal UR appeal process) stands even though IMR denied it after. I hope you are not having any issues with this. Many applicant attorney's are sending every request through UR. If it has been overturned by UR internal appeals process the claims adjuster or applicant attorney can stop the IMR ( but I am not seeing them do this, maybe they are not aware they can)as long as it has not gotten to the point where records were forwarded from IMR company to IMR doctor. After this point the IMR cannot be stopped. Regardless of the IMR outcome your UR approval stands. I do not know if your office is copied when an applicant attorney sends in the IMR, if you are perhaps a staff member can contact the AA office and ask them to cancel the IMR once you receive the UR approval. I agree with you that AA should wait on UR appeal but CAAA teaches their AA's to send immediately to avoid deadlines. (watching their podcast class on SB863) You should be applauded as well for doing internal UR appeals for your patients. You are also one in 1000, other than those who appeal big things like surgery. I place no blame on those doctors because I am very well aware of the time it takes to appeal these, and they do not to my knowledge get paid for their time to do so. I agree with you on your comments about these guidelines.

Pete Thomas Nov 3, 2016 a 7:58 am PDT

IW, I think we have had this issue come up before on a different post. I agree with you that the UR approval SHOULD stand; BUT, it requires yet more time spent, more letter writing, and contacting the adjustor to make sure he/she does not automatically abide by the IMR decision. In the meantime, the requested treatment remains denied "per IMR" and the injured worker suffers the repercussions. In the latest case, I did contact the AA as soon the IMR application letter came in, but by the time AA sent a letter asking to retract the IMR based on a certified appeal, the IMR decision had already been issued! It is just tons of extra work on the part of the doc that is never required in an HMO or PPO system.

Frank Huljev Nov 3, 2016 a 7:58 am PDT

The patter is always the same, when you have physician reviewers in cubicle it quickly become nurses and others who are penning the reports. Dateline in the 90's did investigations on physician reviewers in the auto industry. They found the doctors and sadly even those doctors said it as their signature but that they never saw those cases. The carrier hired journalists to create templates on the files. Why do you even need Nurses? UR and IMR is behind the curtain and i am sure no good is happening. You don't need to see your victims tears and so your making a living. sad

Anonymous Nov 21, 2016 a 10:49 am PST

Your UR approval (by internal UR appeal process) stands even though IMR denied it after. I hope you are not having any issues with this. Many applicant attorney's are sending every request through UR. If it has been overturned by UR internal appeals process the claims adjuster or applicant attorney can stop the IMR ( but I am not seeing them do this, maybe they are not aware they can)as long as it has not gotten to the point where records were forwarded from IMR company to IMR doctor. After this point the IMR cannot be stopped. Regardless of the IMR outcome your UR approval stands. I do not know if your office is copied when an applicant attorney sends in the IMR, if you are perhaps a staff member can contact the AA office and ask them to cancel the IMR once you receive the UR approval. I agree with you that AA should wait on UR appeal but CAAA teaches their AA's to send immediately to avoid deadlines. (watching their podcast class on SB863) You should be applauded as well for doing internal UR appeals for your patients. You are also one in 1000, other than those who appeal big things like surgery. I place no blame on those doctors because I am very well aware of the time it takes to appeal these, and they do not to my knowledge get paid for their time to do so. I agree with you on your comments about these guidelines.

Pete Thomas Nov 3, 2016 a 7:58 am PDT

IW, I think we have had this issue come up before on a different post. I agree with you that the UR approval SHOULD stand; BUT, it requires yet more time spent, more letter writing, and contacting the adjustor to make sure he/she does not automatically abide by the IMR decision. In the meantime, the requested treatment remains denied "per IMR" and the injured worker suffers the repercussions. In the latest case, I did contact the AA as soon the IMR application letter came in, but by the time AA sent a letter asking to retract the IMR based on a certified appeal, the IMR decision had already been issued! It is just tons of extra work on the part of the doc that is never required in an HMO or PPO system.

Gary Tobia Nov 3, 2016 a 7:58 am PDT

Well never fear be creative - start adding claims adjusters as a co defendant within the pleadings of good old 132a - if the situation warrants.

You also have the remedy of a Sanctions Petition for the denial and also now should be able to go outside the MPN and all the other good things that the insurance industry has received with the so called "reforms" over the past years.

Now also an applicant who is a vet can also now be able to go to the VA for better quality medical care also. The vet may have to pay a co pay - so what save the billings and take it in front of a WCJ - start running up the costs for the defense firms - that is what the insurance industry wants anyway, so provide their wishes - more litigation not less - seems the whole system since the 1980s has been going down hill - glad I am soon out of the racket and going into full retirement - but never fear I can also do Pro Bono for injured workers also

Anonymous Nov 21, 2016 a 10:49 am PST

Your UR approval (by internal UR appeal process) stands even though IMR denied it after. I hope you are not having any issues with this. Many applicant attorney's are sending every request through UR. If it has been overturned by UR internal appeals process the claims adjuster or applicant attorney can stop the IMR ( but I am not seeing them do this, maybe they are not aware they can)as long as it has not gotten to the point where records were forwarded from IMR company to IMR doctor. After this point the IMR cannot be stopped. Regardless of the IMR outcome your UR approval stands. I do not know if your office is copied when an applicant attorney sends in the IMR, if you are perhaps a staff member can contact the AA office and ask them to cancel the IMR once you receive the UR approval. I agree with you that AA should wait on UR appeal but CAAA teaches their AA's to send immediately to avoid deadlines. (watching their podcast class on SB863) You should be applauded as well for doing internal UR appeals for your patients. You are also one in 1000, other than those who appeal big things like surgery. I place no blame on those doctors because I am very well aware of the time it takes to appeal these, and they do not to my knowledge get paid for their time to do so. I agree with you on your comments about these guidelines.

Pete Thomas Nov 3, 2016 a 7:58 am PDT

IW, I think we have had this issue come up before on a different post. I agree with you that the UR approval SHOULD stand; BUT, it requires yet more time spent, more letter writing, and contacting the adjustor to make sure he/she does not automatically abide by the IMR decision. In the meantime, the requested treatment remains denied "per IMR" and the injured worker suffers the repercussions. In the latest case, I did contact the AA as soon the IMR application letter came in, but by the time AA sent a letter asking to retract the IMR based on a certified appeal, the IMR decision had already been issued! It is just tons of extra work on the part of the doc that is never required in an HMO or PPO system.

Janine Bowman Nov 3, 2016 a 7:58 am PDT

It's not that doctors universally are requesting outside the treatment guidelines, but rather CERTAIN doctors are. It would be interesting to see, by percentage, who the top 25 percentage denials belong to as I bet it is the same names over and over. In our office, the doctor's in the MPN almost never (if ever) get sent through the IMR process so again, almost all treating doctors would not have been removed from the MPN's.
We find that when appropriate doctors are requesting appropriate care and it is denied by UR, it is usually because something hasn't been considered (standing xrays for major back surgeries) and those are usually remedied and subsequently approved rather quickly.
Does everyone remember that group health must approve treatment and that can also result in delays and denials of care? It's not just work comp
As for the records reviewed, if there is no trust by the applicant attorneys that the insurance carriers provided the records on the index, is there anything to stop them from providing their own?

Anonymous Nov 3, 2016 a 7:58 am PDT

Your right and group health care sucks!!! Ever since HMO and PPOs have taken over. And now we are turning California WC into a giant HMO. So why expect a different result. It Sucks. It started in 2004 and then was reinforced with SB 863. Labor code 4600'which used to be the backbone of the system is now distorted and irrelevant in the eyes of judges and the DIR. It's an inside political job that has been carried out. If you cant see that you are in denial.

Anonymous Nov 21, 2016 a 10:49 am PST

Ibrown I provide records when I appeal UR internally or with an IMR and also know other IW's who are doing this. What I have seen with IMR is they are not reading the records I sent as it addresses the reasons for denial, but same rational is used to deny even though I provided records stating otherwise. I think if I had a half an hour with you and showed you appeals I have done for myself and others and the IMR response, you may just have another opinion. It is easy to blame the statistical data provided about certain doctors doing high volumes of IMR appeals. I would like to know if these doctors are providing an appeal letter with rational and medical records? These offices may just be going through the motions of IMR request appeal to satisfy the patient or out of obligation. If this is the case I do not see the fraud and in fact it is a patients right to allow their doctor to request an IMR on their behalf. If these doctors are just sending in the IMR form (applicant attorneys as well) and not providing anything else, it will be denied by IMR. There is nothing stopping applicant attorney's from providing records and I know some who do...but unlike the claims adjuster they do not get paid to do so. I would like for some of you to try to appeal a denial and handed a file of a patient to do so. It takes a lot of time to go through the file (especially older claims) make copies, look up appropriate treatment guidelines and answer all reasons for the UR denial. Try doing one and tell me how anyone can expect an applicant attorney or doctor to do this as there is no reimbursement for this and stay in business. I would like someone who feels this system is fair to explain how an injured worker, who does not speak English, does not have their medical records, limited education, does not have a computer and has no knowledge of what a medical treatment guideline is supposed to put together a successful appeal to IMR? The expectations are too high with what is needed to get requests approved and this system that does not reimburse doctors or applicant attorney's for their time to do this appropriately.

Anonymous Nov 3, 2016 a 7:58 am PDT

Soothsayer is spot on. The DWC does not give a S@!t. The article might as well say. When Maximus was listing the medical records, IMR was taking months and months to make decisions. Now that they do not have to list the records IMR only takes 30 days and everything is denied. And you have no real recourse. All the judges have been brainwashed to execute the legislature and the DWC's intent.

Total Joke of a system. I do work in about 16 different states, and California is the laughing stock of them all. No where is this screwed up.

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

2nd time: I see drug testing going for Independent Medical Review (IMR), I see opiate weaning going for IMR, I see food supplements going to IMR, I see excess physical therapy/ chiropractic treatments far above 24 visits going for IMR, I see spine surgeries going for IMR when the EMG/NCS & MRI do not support. I see surgeries for arthritic conditions going for IMR.

There are times when I see IMR over turn the UR for the above treatment requests.

Reasonable or not, request being sent for IMR. only the employer or insurer will pay the cost for the review.

Seems that necessary medical care supported by scientific medical evidence is no longer the reason a request is sent to Maximus for an IMR.

I'm just a lowly CE and probably will be considered in err for my comments; so, have IMR produce the list of medical treatments that they have seen for review.

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

Truth be told - a ghost doctor can only [not] read ghost records....

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

A ghost doctor can only read ghost records.

Steven Baron Nov 3, 2016 a 7:58 am PDT

The IMR system is a joke! I spoke to a physician who performs about 100 of these IMRs per month. He hires a nurse to insert boiler plate information and just signs off on them. Pays the nurse 30$ per IMR and keeps the rest. What a scam!

Jack Goodchild Nov 3, 2016 a 7:58 am PDT

The emperor has no clothing but the powers that be don't care!

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

Someone should report this doctor instead of complaining about what he is doing on a message board.

Anonymous Nov 21, 2016 a 10:49 am PST

I can tell you as a person who appeals UR denials through the internal UR appeals process and have also been involved with trying to get approvals with IMR....IMR reviewers are not only failing to properly list records, they do not list the advocate letter I write with the patients history, rational to why the request is warranted AND relevant treatment guidelines. They do not list it and it looks like they do not read it either. I provide everything that was missing and why the original UR was denied and appropriate guidelines. My limited dealings with IMR is they are not reading the records or cover letters I send. For a while I was wondering if for some reason my advocate letters were not being forwarded to the IMR reviewer from the IMR company, but how would I know if this is the case or he is not listing this document.

I have a 90% rate to overturn a UR denial through a UR internal appeals process and with IMR I have not gotten one overturned. Some of these IMR doctors are clearly not reviewing the advocate letter I send with guidelines or reviewing the records and just regurgitating what the original UR denial stated. Why I believe my appeal system is not working with IMR as it is with UR is they do not have to provide their name. If this happened with UR, and the reviewing doctor blatantly disregarded the information I sent, I could contact the UR company discuss this with a supervisor, file a UR complaint and have the requesting doctor make another request under change of material facts known.

I have to admit I have not had to deal with IMR a lot because I can usually overturn a UR denial for myself and the other injured workers I have helped through UR internal appeals process. My perception is based on a limited number of IMR reviews, but enough for me to think there is a problem and I am going to request the medical unit review my documents. When an IMR doctor fails to list records or my cover letter I believe it is grounds for a doctor to make the request again under material facts not known in previous review. This of course causes the injured worker delays and those who are scamming the system (IMR reviewers who are not reading the records sent) will make more money if this ends up under IMR again.

I absolutely believe there are cases it is not an actual doctor who is doing the IMR and often times UR denials. Anyone who has read enough of these can see it clearly. I have been told by a nurse at a major UR company over the phone that it is nurses who do the UR determinations and are legally able to do this under the umbrella of the doctors electronic signature (whatever that means). This was a number of years ago, before the passage of SB863. I do not know if this UR company is still doing this, but I do not see how it could be legal. I also have a UR denial that was written and signed by a UR doctor only to find the UR doctor approved the request...but someone at the UR company sent a denial out with rational to deny. I found this out my having the PTP doctor re-request it. It came back denied due to previous UR doctor approved the request. I investigated it further and found in the UR CO doctors notes it had been approved, but apparently at this UR company a nurse types out the UR doctors determination as a denial.

As an injured worker and advocate for other injured workers I have seen a lot of fraud in this system including medical provider, UR/IMR, and employer. It is really discouraging. I get more upset when I see this happen to other patients who are in a more serious medical condition than I. Dealing with these shenanigan's is wearing on me.

I have on the other side of this seen some good behavior by people working in UR and IMR. One example a UR nurse working late to get a request approved and advised me what are the things she needs to get the request approved. I read a lot of IMR determinations on the states website, and reviewing some that were overturned it is evident the IMR doctor reviewed the records and in some cases went beyond and found guidelines more appropriate than what was used outside of MTUS, ODG etc. There are people in IMR and UR doing the right thing, just not enough of them.

Ashleigh Rivera Nov 3, 2016 a 7:58 am PDT

IW - where would an applicant attorney go if they need to find a dedicated UR-overturn helper like you?

Anonymous Nov 21, 2016 a 10:49 am PST

caiwadvocate101@gmail.com I will show any applicant attorney or IW how I appeal UR denials.

Ashleigh Rivera Nov 3, 2016 a 7:58 am PDT

would it be better if California had opt-out plans available for Employers, like TX and OK?

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

Perhaps the AAs and doctors posting here had a better solution for the runaway and unnecessary treatment being performed that resulted in the UR process. I don't recall hearing any solutions presented by them that would've put a stop to those problems. If you think the current batch of doctors under indictment and investigation are the only ones doing bad things then you are naive. They're the only ones who have (currently) been caught. I know several people in the SIU department of a few insurance companies and trust me when I tell you that they are currently building cases against several other bad players. So, let's hear a "solution" from someone. Or perhaps we should simply defer to the treating doctors because they're graduates of Stanford and UCLA as someone else posted.

David Stein Nov 3, 2016 a 7:58 am PDT

So the SIU folks you know are busy illegally hacking into servers and pocketing chunks of cash by exploiting the illegal activities they pretend to be fighting. DART, either you are the naive one or part of the problem. Do us all a favor and turn them in. You know who they are and what they are doing.

Anonymous Nov 3, 2016 a 7:58 am PDT

If a doc is doing something illegal send him to the DA and report to CMA and AMA. Put him out of business just as a body shop that was ripping off insurance companies would. UR is nothing more than a denial sales company. IMR is nothing more than a rubber stamp on the purchased denial. Any of you that hire UR companies cannot deny it. You have conference calls and meetings about what you would like to see less of and what you would like denied across the board. Stop pretending it is a legitimate process that is un-biased. It's getting old

News Articles

Friday, October 23, 2015

Attorneys Say Maximus Not Listing Medical Records in IMR Letters

14 Comments (13 Replies)

Anonymous Nov 3, 2016 a 7:58 am PDT

Manila Manila Nov 3, 2016 a 7:58 am PDT

Richard Moser Nov 3, 2016 a 7:58 am PDT

Pete Thomas Nov 3, 2016 a 7:58 am PDT

Anonymous Nov 21, 2016 a 10:49 am PST

Pete Thomas Nov 3, 2016 a 7:58 am PDT

David Stein Nov 3, 2016 a 7:58 am PDT

Anonymous Nov 21, 2016 a 10:49 am PST

Pete Thomas Nov 3, 2016 a 7:58 am PDT

Rodolfo Garcia Nov 3, 2016 a 7:58 am PDT

Anonymous Nov 21, 2016 a 10:49 am PST

Pete Thomas Nov 3, 2016 a 7:58 am PDT

Frank Huljev Nov 3, 2016 a 7:58 am PDT

Anonymous Nov 21, 2016 a 10:49 am PST

Pete Thomas Nov 3, 2016 a 7:58 am PDT

Gary Tobia Nov 3, 2016 a 7:58 am PDT

Anonymous Nov 21, 2016 a 10:49 am PST

Pete Thomas Nov 3, 2016 a 7:58 am PDT

Janine Bowman Nov 3, 2016 a 7:58 am PDT

Anonymous Nov 3, 2016 a 7:58 am PDT

Anonymous Nov 21, 2016 a 10:49 am PST

Anonymous Nov 3, 2016 a 7:58 am PDT

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

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

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

Steven Baron Nov 3, 2016 a 7:58 am PDT

Jack Goodchild Nov 3, 2016 a 7:58 am PDT

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

Anonymous Nov 21, 2016 a 10:49 am PST

Ashleigh Rivera Nov 3, 2016 a 7:58 am PDT

Anonymous Nov 21, 2016 a 10:49 am PST

Ashleigh Rivera Nov 3, 2016 a 7:58 am PDT

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

David Stein Nov 3, 2016 a 7:58 am PDT

Anonymous Nov 3, 2016 a 7:58 am PDT

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