Workers Compensation Reform 2012 Part I: Independent Medical Review

Ley de Compensación de Trabajadores

Workers Compensation Law 2012

Workers Compensation Reform 2012 Part I: Independent Medical Review

Senate Bill 863 introduced a new concept into workers compensation called independent medical review. This process will be handled by a national company called Maximus through the California Department of Industrial Relations Division of Worker’s Compensation. Independent medical review will change how medical authorizations for treatment and procedures are handled. Traditionally the treating doctor, utilization review, qualified medical examiners, or agreed medical examiners had the final say on what is authorized and what is not as it pertains to medical treatment.

The attorneys at the Law offices of Cleveland and Metz can help you through this workers compensation process and help you understand the new workers compensation law and how this work comp reform affects you as an injured worker. The process essentially removes the final say of your medical treatment from a physician that actually examines you to a physician that will never examined you and make medical determinations based on the medical documentation submitted to the independent medical review company. A lawyer with the Law Offices of Cleveland and Metz can help you make the right choices in your workers compensation case.

The following is a list of questions and answers posted by the California Division of Worker’s Compensation:

What is independent medical review (IMR)?

IMR was established by SB 863 to provide a quick, efficient way of resolving medical treatment disputes. If a request by a treating physician for a specific course of medical treatment is delayed, denied, or modified by a claims administrator for the reason that the treatment is not medically necessary, an injured worker can ask for a review of that decision by an independent, qualified physician. The assigned physician reviewer, selected under stringent standards, will review relevant medical records and apply recognized treatment guidelines to determine if the requested medical treatment is appropriate for the injured worker’s condition. The IMR process should take about 40 days to complete, which is significant improvement over the current system – which can take up to a year – that heavily relies on state-certified medial evaluators and judicial decisions.

 SB 863 requires that the IMR process be administered by an independent medical review organization (IMRO) chosen by DWC. Oversight of the program will be conducted by DWC’s Medical Unit. The use of an IMRO will ensure the assignment of unbiased medical experts for treatment reviews.

 When will IMR go into effect?

IMR will be available on Jan. 1, 2013, for all occupational injuries occurring on or after that date, and on July 1, 2013 for all dates of injury.

 How will I be able to request IMR?

IMR can be requested following a delay, denial, or modification of a treatment request by the claims administrator’s utilization review process. With the decision letter, the claim administrator must provide a form for the injured worker to request IMR. The form should be completed and timely returned as instructed to start the IMR process. An injured worker can be assisted by an attorney or by his or her treating physician in the IMR process.

 Will there be any changes in the utilization review (UR) process?

Beginning on Jan. 1, 2013, for all occupational injuries occurring on or after that date, and on July 1, 2013 for all dates of injury, DWC will require the use of a Request for Authorization (RFA) form that must accompany all treatment requests made by treating physicians. The RFA form will specify treatment requests and identify disputed issues to help the injured worker and claims administrator resolve differences before turning to IMR.

 Also, SB 863 will allow injured workers and claims administrators to defer to UR referrals if there is an issue in dispute over anything other than the medical necessity of a particular treatment requested by the injured worker’s treating physician (such as cases where the injury itself or the injury to a specific body part is in dispute). UR decisions will be now be in effect for 12 months, allowing claims administrators, absent any documented change in facts, to reject duplicate treatment requests.

 Will the IMR physician reviewer conduct an examination?

No, the IMR physician reviewer will not conduct a hands-on examination of the injured worker. The physician reviewer will analyze all relevant medical records and information submitted by the employee, the treating physician and the claims administrator. The parties will be instructed by the IMRO, once an IMR request is accepted, as to the types of records and information that must be submitted for review.

 What is the difference between a qualified medical examiner (QME) physician and an IMR physician?

In terms of medical qualifications, there may not be a difference between QMEs and IMR physicians, as both have to be licensed and in good standing, with appropriate training and experience. QMEs are, and will continue to be, certified by the State of California. IMR physicians will be screened and certified by the IMRO, applying criteria developed in consultation with DWC.

 Can a QME also be a reviewer in the new IMR program?

Starting Jan. 1, 2014, a reviewer in the IMR program may not also hold an appointment as a QME. A physician who wants to be a reviewer in the IMR program next year would need to apply to the IMRO. 

What is the time limit for the IMR decision to issue and can it be appealed?

The statute requires the IMR organization to issue a determination within 30 days of receipt of all necessary records. IMR appeals will be considered by a workers’ compensation judge. However, the IMR physician reviewer’s decision on the medical necessity of the medical treatment cannot be overturned by a judge. A decision can only be overturned on the basis of fraud, conflict of interest, or mistake of fact. 

Who has to pay for IMR?

The claims administrator will pay the reasonable per-case cost of IMR. The cost will be determined by the IMRO in conjunction with DWC and set out in regulations. 

How long will an injured worker have to wait for an IMR decision before receiving treatment?

Insurers and claims administers are required to promptly implement an IMR determination approving disputed treatment. 

What happens when the spinal surgery second opinion process stops? How will these issues be resolved?

If a disagreement arises over spinal surgery after Jan. 1, 2013 for dates of injury on or after Jan. 1, 2013, the UR denial will be resolved through the IMR process. Between Jan. 1 and July 1, 2013, for dates of injury before Jan. 1, 2013, QMEs will address spinal surgery issues. After July 1, 2013, for all dates of injury, spinal surgery issues will go through the IMR process.

Submitted by:

  Charles Cleveland