To date, 94 percent of medical treatment requests are approved after initial/internal UR and elevated physician-based UR.
At most, 4.7 percent of all medical treatment requests are denied.
At most.
Those are the headlines from CWCI’s just released analysis of all completed IMR decisions (see 1/8/14 report), an exhaustive and precise project that involved a manual review of each of those requests and resolution thereof.
CWCI’s summary indicates “IMR agrees with approximately 79 percent of the elevated physician-based UR decisions.”
What does this mean?
There are two main takeaways. First, there’s no widespread denial of care to injured workers, far from it. The research clearly demonstrates that while the vast majority of treatment requests are approved, the vast majority of the IMR decisions uphold the UR determination to deny or modify treatment. (Update)
Which leads to takeaway two. Do not assume this means the IMR process – or UR itself is unnecessary or superfluous. While a cursory review of the results would lead an uniformed reader to draw that conclusion, the report provides insight into the potential downside of ending UR. The authors reviewed a study conducted by the Washington state work comp fund, known as L&I. Back in 2000, L&I stopped requiring UR for MRIs, as almost all were approved. A few years later, they looked at the volume of MRIs conducted had jumped dramatically.
Here’s what they concluded:
L&I reviewed the effect that the elimination of UR had on MRI use and found a 54 percent increase in spinal MRI scans and a 72 percent increase in lower extremity MRI scans following the elimination of utilization review, and the reviewers were unable to identify any variable other than the removal of the UR requirement that accounted for the increase in MRI utilization. [emphasis added]
Other research into California-specific utilization further emphasizes the risk of ending UR, you can find it in the report at the link above.
That said, there’s no question the volume of IMR requests is much higher than anticipated; word is the State is considering various ways to address the volume including adding other vendors. But focusing on results to date, it is also clear the process is working as intended – as an exception management process.
As stakeholders gain more experience with UR and IMR, I’d expect the volume of requests to decrease.
What does this mean for you?
We know now that the IMR process is not a “medical treatment denial scheme” perpetrated by carriers looking to deny care.
Far from it.
Joe, Colorado passed a ‘loser pays’ addendum and the number of IMR’s decreased significantly. If the lawyers had any skin in the game, you would see the number of unnecessary IMR’s decrease significantly.
20,000 IMR request a month at $560.00 per request, that $10 million dollars a month being taken out of the WC system, someones making a lot of money.Was the volume unepected or a plan for someone to profit. You now that you cannot compare Washington to California,
jg – thanks for the comment. A couple points.
1. The IMR requests came from the treating doc. You might want to ask them why they did this.
2. I certainly can compare WA and CA; moreover CA specific information supports the sentinel effect inherent in UR. It is in the study, which is free for download.
In California, a treatment request cannot go to IMR untill it goes to UR. Only the insurance carrier can send a treatment request to UR. The State is holding meetings next week to try to resolve the IMR problem. The volume of IMR is so high because most payors are sending every treatment request, even ones from there own MPN doctors, to UR. The UR and IMR cost, in most cases are past on to the employer. Some carriers own UR companies. Sorry for the typos.
jg – good point – thanks for the clarification. I should have been more precise and noted IMR is used when a physician decides to dispute a UR finding, thereby forcing an IMR.
Physicians are actually prevented from filing an IMR except in cases when the treatment was provided on an emergency basis. Under normal circumstances, IMR must be filed by the injured worker or the injured worker’s designee.
Sarah – thanks for the comment. I addressed this in my response to jg’s comment. By far the most IMRs are done at the payer’s request
Sarah,
You are absolutely correct. Until the desgnee (AKA attorney) has some skin in the game, they will keep filing the IMR’s.
I am unsure where you are getting your facts from but the web site you quoted has been taken down. To be clear; 85% of the treatment requests in my clinic are not correctly responded to by the adjustor, despite my attaching a full report, attaching an RFA request form for each request, attaching the updated MTUS ODG guidelines for California for each request, and faxing the packet (often 27 pages for three requests) to the adjustor. There is a $5k fine for every major deviation for the adjustor (of the thousands at my clinic not a single fine has been assessed by the DWC!). Of the few, that come back correct, there is an IMR form in the back of the packet that no patient knows what to do with, and is almost always filled out wrong (this is a $2K fine again none assessed by the DWC). The adjustors are taking multiple requests (with individual RFA’s) and bundling them together for IMR review (surgery, meds, PT, etc). Since the IMR’s are not allowed to modify them, and denying any one of them denies them all, almost 70% or more are denied for ALL the bundled treatments. No appeal for any one of them, no repeat requests for a year, done gone finished. The IMR’s are not even happening for most people, and so most care is in limbo (only 5k of 70K have occurred) and some are still in limbo from July when the law started.
The last kicker is that they are not even coming close to following the rules of using best treatment guidelines. Almost always ACOEM is used which has a AGREE rating of 18%! (implying they should never even be used in many instances).
It is a perfect storm of over-administration, with the presumption of giving care. Carriers are likely keeping more than 70% of mandated fees (it was 60% “administration fees” i.e. profit after SB 899).
To obtain care, I need to get past the AME/QME process, the adjustor ignoring the request, or bundling all requests together, Peer to Peers reviews 5 a day, UR review that are biased, incorrectly completed IMR processes, delays in IMR occurring, and very substandard guidelines, no due process, no appeals, and potentially blanket taking of the patient by adjustors if they don’t like the requests, or deny payments to the doctor.
I have patients literally dying from this law.They are losing homes, families, and any potential for return to work and many moving to destitute poverty. Yes perfect law for carriers
Mark – welcome to MCM. thanks for pointing out the broken link. It has been fixed. I suggest you review the report as it provides details on the source of the research.
As to your appeal process issues, I can’t comment as that is self-reported information. I do know that overall, the IMR process is catching up. I would also note that the IMR process has been flooded by requests from applicant attorneys, a situation that is directly contributing to the delays you appear to be experiencing.
Interested in your thoughts after you review the report.
Thank you for your comments. I am confused by the presumption of such a low denial rate, when the analysis states that there is about a 78% rate of upholding the denial decision by the UR reviewers. If one reviews the UR reviews one would see that almost all of them are based upon inadequate records being sent to the UR reviewer, however thorough the records actually are for the documentation. And here is the challenge to patient’s. The current law requires that the PATIENT send the UR denial for the IMR process (why not the adjustor when they have it). Paient’s don’t even know they are entitled to an IMR (when it actually is sent with the denial at all, or responded to at all). This is why applicant attorney’s are attempting to fill them out for the patient (they are not “driving it”). IMR, as you know, has only reviewed a very minor fraction of the ones that are to be completed, and when they do evaluate a case, they are allowed to review bundles of requests for one patient at a time, with no modification just denial, or authorization. So again, the lack of records for Ambien that gets sent to IMR gets bundled with surgery, with excellent documentation and both are denied for a year with no chance of appeal.
I am looking at 95% denial of all care, across the board, for everything, with only a few actually get to the IMR process (due to confusion of paperwork by the patient, lack of understanding of the timelines by the patient, lack of having the UR review the patient now has to send, lack of time for the MD to fill the paperwork, (whom is mostly a secretary to the UR review), etc, and then no appeal for a year from IMR. This was a perfect law to take away care.
This was a brilliantly played law, to simply add three more levels of seemingly neutral review, make them impossible to appeal, and then not file a single fine to the carriers who break the law for almost every case, every day, just stop the care when the paperwork is not completed for the patient.
If I planned on anyone obtaining any treatment through any carrier in the future, I would be very afraid that this is the new way to do business.
Mark – thanks for the note. I’d just reiterate the study looked at all the requests; perhaps your situation is unique.
I am appalled at yet another study executed by stakeholders in the insurance industry using data supplied by only insurance carriers. Bravo, boys. My grandmother would call this the fox guarding the hen house. Even more galling is the strutting and crowing of blatantly deceiving statistics such as only 4.7% of medical requests for treatment are being denied. With UR requests inundating the system by the tens of thousands on a monthly basis at a cost of $560 each it is no stretch to understand who is benefiting from the system changes brought about by SB 863. I am an educated professional who has had the misfortune of being trapped in the California Worker’s Comp system for two and a half years. All requests for treatment made by my treating physician since the implementation of SB 863 have been denied. All. 100%. All pain medications that were routinely approved are now routinely denied. All diagnostic testing is denied. All. My case is now considered surgical by three physicians including the AME. Any and all treatment has been denied at the UR level. My attorney has filed all forms requesting IMR on my behalf. His office now files on an average 100 dispute forms on a weekly basis, I am told. Even the CHSWC states in their 2013 annual report that no one anticipated or was prepared for the flood of IMR request that have been the result in the change in legislation. They further state that any savings in administrative costs and potential savings in medical treatment costs are in serious jeopardy. So while the insurance companies are clearly benefiting by denying treatment, injured workers go untreated, are unable to return to meaningful work and face very bleak and hopeless futures. A serious evaluation of the status and effects of the current UR and IMR process is incomplete without considering the objective experience in dealing with the new law from the treating physicians, legal representation and, lastly, the person whom this system is supposed to be serving, the injured worker. The comments made by Mark King are sobering and frightening. His statements are a clear indication to me that this system is being run by third party payers who are focused on their own wealth and have a complete disregard for the value of the treating physician and for the health of the injured worker. After two and a half years in this system, my attorney has advised me to engage my private medical insurance to receive the treatment I need to restore my health and return to work. He states that he is now giving this advise to many of his clients. I am heeding this advise as I am convinced choosing otherwise will mean languishing in a system that rewards those who are routinely denying care and penalizes those who are simply trying to provide care to those who desperately need it.
Lisa – I’d note that the IMR data came from DWC, not insurance companies. If you haven’t yet had the opportunity, you may want to review the report itself; there’s a link in the post.
I have to disagree with this article’s conclusion mainly because the data itself is biased. Here’s my reason. I’ve been a peer reviewer for CA WC for couple of years. And there are couple of issues at hand. The UR can be approved by Nurses or adjustors. So vast majority of cases never goes to the physician reviewer. That 94% approval rate probably represent mostly these initially approved treatments such as initial trial request and such which are pretty much guaranteed to be approved. What matters is the cases involving clinical decisions where denials, delays, or modifications can be made. Once UR nurses determine the cases require clinical decision, it is referred to the physician reviewers. Physician reviewers are either indirectly influenced or sort of go through weeding out process. Some reviewers feel that they need to deny as much as they can in order to get more cases. And the UR company itself stops using those who approve or deny too much in order to decrease liability. They look for about 80% denial rate. If someone goes astray too far from the number, they are cut. AS for IMR reviewers, they are also under the pressure of getting more cases from Maximus.
In order to keep the UR process truly independent, they need to form a panel where reviewers are randomly chosen. As long as someone has power to influence one’s participation in anything, there’s soft pressure.
I have been out of work for over two years due to QME, UR, and IME’s that go back in forth practically every month. The QME stated I needed surgery & the UR, and, IMR says I don’t & then a few months later that that I do! Then there is the whole medication mess that goes back and forth too! Sometimes I have to pay cash and the next month the same med is covered. Thank God I have an attorney for most of the paper chasing. I wish I had other insurance that actually works! This isn’t working for the injured worker! Instead of seeing an orthopedic surgeon for an orthopedic problem that is seen in both x-Ray and Two MRI studies, I am still being handed a monthly prescription for meds from a frustrated pain management specialist! Since the first MRI & QME till now, two years later they probably could have given me a few surgeries!