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IMR Cases Missing Records Decrease, still Number in Thousands

  • State: California
  • Topic: Top
  • - Popular with: Employer
Medical records are at least 90 days late in more than 5,000 independent medical-review cases submit…

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14 Comments (8 Replies)

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Dave Vaverka Nov 3, 2016 a 2:58 pm PDT

Surprise! IMR is a total failure.

Sue Simmons Nov 3, 2016 a 2:58 pm PDT

I have to agree with Carrier's comment. We, too have a similar process that he/she described. We also get notices from MAXIMUS that the records were not received, but when we check, and re-produce the documentation, they have had to retract their letters and concede that they did, indeed get them.

Another issue that we have is with MAXIMUS telling us that we have not paid their invoices. Here again, we send proof, and never hear another word.

I wish that MAXIMUS would get their data correct as it is painting everyone with the wrong brush.

D C Nov 3, 2016 a 2:58 pm PDT

I called MAXIMUS on a case to see if records were sent by the claims adjuster and was told not yet (still within 15 day period). The customer service rep stated the IW could also send records. I then asked if the IW sent records then would the IMR still go through as the IW does not have all of their relevant records. Not only would the IMR go through the adjuster could not be fined for not sending records if the IW sends records. ???? How does this make sense? If the injured worker sent what they had (which was lacking things needed to get the request approved), the IMR would go through and no recourse to the claims adjuster when the other party sends records.

I have also seen records being sent to MAXIMUS that are not relevant to the request. I left a message to the adjuster to please send the relevant records, which the IW did not have (listed them in a voicemail) and they were not sent.Why would the claims adjuster send relevant records that may get the request approved?

The above was on a case that was partially overturned with UR appeal and the IW was attempting to get it completely overturned.

I wonder how many of the above records counted in this article were sent by the applicant side. MAXIMUS does not appear to keep track of who is sending records. This may hurt pro per injured workers who do not always have their complete file, if they send any records the IMR will go through.

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

Not $0.01 in fines against the insurance industry by a system put in place by the insurance industry? On the contrary, costs to deny medical care to California workers is going down to $390.00 per denial as of 1/1/15.

Cliff Bernstein Nov 3, 2016 a 2:58 pm PDT

I had a IMR denial yesterday based on Medical records 3 years out of date. the reviewer said "no documentation of benefit" even though it is obvious the records were 3 years old. This is outright fraud

Wayne Collins Nov 3, 2016 a 2:58 pm PDT

So when is our illustrious DWC going to enforce they law and start fining these people for being in violation? It is too obvious whose side they are on. The law is supposed to be enforced the same for ALL parties.

Dave Vaverka Nov 3, 2016 a 2:58 pm PDT

Surprise! IMR is a total failure.

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

It is interesting how quickly the DWC is to sanction Lien Claimants for any number of reasons, but how slowly they punish Defendants. Also, notice how the PD awards and medical treatment have decreased over time. But when it comes to this gross negligence by Defendants, the DWC won't lift a finger. Make no mistake, the Defense has hijacked the system and anything pro-Applicant or pro-Provider is quashed. This is the Coase theorem in action. It doesn't matter who wins a given lawsuit challenging the constitutionality of IMR, lien fees, etc. The Defendants are the Highest Valuing Owner and they will just throw more money into the legislative process to produce the outcome that they want. They already control the advisory process by CHSWC. Just ask yourself, when was the last time you saw a pro-Applicant or pro-Treatment legislative bill that truely increased PD (not that created a minor give back of previously lost ground) or expanded medical treatment? So, it is not suprising that when Defendants break the law, nothing is done.

AJ Benham Nov 3, 2016 a 2:58 pm PDT

It would be interesting to know how many of the medical records that were submitted included everything required. I'll bet if someone looked at how many adjustors failed to send "complete" records per the criteria above these numbers would be even higher.

D C Nov 3, 2016 a 2:58 pm PDT

Not only complete records but RELEVANT records. I have seen complete BS sent to an IMR that had little to do with the request.

Manila Manila Nov 3, 2016 a 2:58 pm PDT

This is more evidence of corruption in government. The welfare of injured workers in so many instances is hijacked by a contemporary system created and operated for political reasons but self-proclaimed as "cost-savings." IMR is a joke with anonymous doctors with an insurance bias blanketly imposing one size fits all standards upon people with medical needs. Why not just have robots do the job and save even more. What ever happen to the day when a doctor takes into account the individual characteristics and unique history of a patient in order to make focused determinations and recommendations.

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

how is this evidence of corruption in government?

Gilbert Fisher Nov 3, 2016 a 2:58 pm PDT

There is an easy fix: If the required records are not received within 15 days, as per regulation, then the treatment should be deemed automatically authorized.

Wayne Collins Nov 3, 2016 a 2:58 pm PDT

The DWC is not fining carriers........what a surprise..........our own state government won't enforce the IW get screwed in the process.....where is that in the constitution? It is time that somone holds the carriers responsible and not above the law! Hey your job please

Anonymous Nov 3, 2016 a 2:58 pm PDT

What a shocker!!! Everyone who actually provides services to the injured workers will get fined, can loose accts receivable based on not filing timely SBR or IBR. Providers are left in the dark for over 6 months sometimes wondering what is happening with an IMR or IBR request but the carriers have their henchmen / henchwomen working for them at the DIR. It is a scam and we are all standing by letting it happen. I remember hearing Baker do a talk shortly after the rules took effect and she said " be careful of providers and attys gaming the system" well that is because Baker, Das and the rest of them are doing exactly that. Crooks and cheaters always think everyone else is as well. Just watch over the next few months. I am sure a lot more information relating to their corruption will be made public. It's a sad situation for our state and especially for anyone who gets injured here.

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

Our company gets about 10 notices a month from Maximus stating we did not provide the medical records that were requested. We are able to demonstrate immediately to Maxims that we have already sent them and they have just failed to match the records with the Maximus case.
We ship everything via overnight so we have tracking mechanism in place to verify they received them. This article is incomplete and really didn't even bother to investigate what the data really means.

I know for a fact that many of the GB locations also send via overnight so I really question the statistics in the spreadsheet.

There are also instances where a carrier will have subsequently authorized treatment and the IMR process has started. No records are required at that time.

Further there are numerous large carriers not even listed on the spreadsheet. This looks like somebody either fabricating documentation or somebody with an axe to grind.

Shame on WC Central for publishing this without even doing any investigation or real reporting.

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

And what is really happening is Maximus is overwhelmed from sabotage. It is no secret there is an attempt to overwhelm the system. The impact of course is harm to injured workers whose legitimate appeals are delayed while Maximus works through the thousands of appeals that are duplicates, or filed when the underlying treatment has already been provided. We have even had appeals of UR to IMR when the underlying RFA was approved by UR.

Anonymous Nov 3, 2016 a 2:58 pm PDT

Carrier, I'm curious, do you put the Maximus case number on each record? I heard Maximus can't keep track of the records without the case number on each record causing even more delays and making things appear like there are missing records.

D C Nov 3, 2016 a 2:58 pm PDT

Workcompcentral has a good investigating team and I am sure they did investigate. They have no reason to be biased or untruthful. I find their news team to be fair to all sides.

D C Nov 3, 2016 a 2:58 pm PDT

JPM sometimes I have sent IMR appeals at same time as UR appeal. This is not scamming, it is to ensure I do not pass any deadlines. Then the UR is approved sometimes just before the IMR. It is also possible some injured workers do not understand they were approved by UR and just sent the IMR in. This system is incredibly complicated for injured workers. I also send in an IMR if UR only approved part of the request.

ED HERRERA Nov 3, 2016 a 2:58 pm PDT

I work for one of the biggest TPA's. I can say for CERTAIN Maximus loses many of the IMR records sent to them. because of our size, we get huge lists of alleged non-responses to NOARFI's and of the last 50 all were complied with timely except 1-2 were missed by Examiners. of the others, half were sent (and disappeared), or NOARFI's never received (our mail is imaged by a third party so no chance mail was "lost"). We have numerous cases where they were sent TWICE and they still claim to have not received. And the billing: we just got a list of alleged non payment of IRM billings of the 55 alleged, in 52 of those NO BILLS were ever sent! they are having serious issues and the injured workers are paying the price, not the claims admins.

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

@injured7825: we complete a file and serve cover and return the document with their request on top. They don't lose all of the records we submit I would guess 1 out of 25 go missing. @M: yes they are so good that's why today there is a clarifying story about the missing records. In my opinion the head of WCCentral has become extremely biased. Just read some of his blogs. It is clear that he now hates the insurance community and all he does is bitch about how awful we are and how horrible insurance is. I don't really get why he stays in the business with how much he hates he industry. Why not turn the reigns over to somebody that actually cares about the people in the industry. Unfortunately this is only one site that has the rating and other items that we need to do our jobs otherwise I suspect the insurance community would leave en masse.


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