CWCI’s just-released analysis of the Independent Medical Review program’s 2013-2014 results indicate it is working well – despite being flooded with requests from a relatively small group of docs.
Let’s stipulate that the IMR process is not fool-proof. There’s no question errors have been made and it is likely some patients’ care has been adversely affected. More on that below…
Here are the key data points:
- 94.1% of all medical service requests are approved
- 36% of requests were from the Los Angeles area but only 24% of WC claims
- Of the requests that are NOT approved;
- 45% are for drugs (29% for opioids, 12% for compounds)
- 10% for DME
- 9% for PT
- 1 out of 17 medical service requests are modified (the treating doc agrees with the reviewer to do something different) or denied
- review encompassed 260,889 medical services requested for 76,718 patients
- 75% of reviewers’ guideline summaries cited the CA Medical Treatment Utilization Schedule; 80% of those cited either MTUS alone or MTUS and non-MTUS guidelines (there’s a lot of additional info in the report on pp 19-21 re guideline usage)
Okay, that’s the data, big-picture stuff. What’s perhaps even more revealing is what some docs wanted to do to patients. For example;
- one wanted to administer Propofol to a patient getting a steroid injection because the patient gets “anxious”. recall Propofol killed Michael Jackson, and is by no means appropriate for an ESI.
- another wanted to fuse “every vertebra from the pelvis to the middle back in a 76-year old patient”, despite no documentation of a lesion, neural compromise, or “other clinical finding supporting the procedure”
- I’ve also heard from a credible source (not in the report) that aspirin was denied to a patient because that patient was already on blood thinners…
What’s abundantly clear is the UR/IMR process has undoubtedly prevented medical catastrophes; opioid addiction, failed back surgeries, adverse drug reactions.
As noted above, we can also stipulate that the process is by no means perfect, however the reasons for those errors are by no means clear. It certainly appears that the huge volume of IMR requests (the top 1% of docs accounted for 44% of all requests; 10 physicians alone accounted for one out of every seven requests!) overwhelmed the system initially, altho of late requests are being processed on a much more timely basis.
The exhaustive, 24-page review concluded with this statement:
The Workers’ Compensation Insurance Rating Bureau of California recently announced a significant decrease in medical benefit development coupled with a significant increase in expenses related to the delivery of medical benefits. IMR is likely to be associated with both trends. [emphasis added]
What does this mean for you?
Evidence-based medical guidelines backed up by a tight UR process prevents a lot of crappy medical care. It can also be cumbersome, and is by no means perfect.
Very nice breakdown of the reality. As a third party administrator we are very focused on providing timely and appropriate care to injured employee’s to facilitate return to work and recovery. Everyday we have a clear picture of the vast majority of treatment that is authorized. Unfortunately, we are often lumped into the “always” and “nevers” surrounding the authorization of treatment.
Thank you for sharing the objective data that truly hones in on treatment trends that legitimately necessitate the need for a second set of expert eyes.
But thank goodness for IMR. Even if it’s a miniscule number of cases that are as outrageous as the examples cited, saving even one person from harmful medical treatment should be celebrated.
Definitely encouraging. Experience does show that legally UR “Authorization” is simply assurance that appropriate payment will be made for a medical service; and conversely, UR denial doesn’t mean reaching in and stopping the hand before it writes the prescription. We see many providers who will simply dispense and/or administer high-risk treatments prior to even requesting authorization and still attempting to treat on a lien basis regardless of treatments being in some cases frankly egregious. (A personal favorite is the compounded cream with a tricyclic antidepressant, an opioid and a cough suppressant… laughable) The big question is was the treatment actually provided and was payment actually not made for treatments that go against guidelines and standards of medical practice. We definitely have a long way to go. Thank you so very much for the article and the information, let’s see what the future holds.
As an injured worker in the California, it is very difficult for me to believe the statistical data on approval rate for UR approvals, and believe as many on the applicant side that it is not accurate for those who have serious, or long term injuries in California. Most of my doctors requests are originally denied by UR. I have to personally appeal each denial by providing medical records and looking up medical treatment guidelines. I have been able to get most UR denials overturned. I would not be receiving much of any medical treatment if I did not have this skill set.When I have helped other injured workers or applicant attorney’s with their appeals, they usually get them overturned, but it is so I do not think it would be cost effective for an attorney or doctor to do this task for every patient on every denial.
Reviewing my own UR denials as well as other injured workers denials I have found many UR and IMR denials are based on guidelines that are used incorrectly or do not reflect the patients condition. Some of the guidelines used are just a portion of the guideline quoted to deny, when in fact the entire guideline stated the request was warranted. I have used the same guidelines to overturn denials that were used in the original denial due to this. Something is wrong if UR companies are doing this.
When I discuss my opinions with doctors in this system they are shocked I have found out what they already see regularly. They do not have the time nor would they get paid for appealing a patients denials like I do. It is very time consuming to go through my records to find relevant reports and testing’s to do my appeals, especially when I do not feel well due to my industrial injury.
I would love to share my UR denials and documentation of appeals Mr Paduda. I believe you will be surprised at what is really going on in regards to UR and IMR.
Regardless of my difference of opinion, I enjoy your blog.
Working well? For whom? Certainly not for injured workers. I beg to differ. I am disabled and now suffer from CRPS and have a court order after going to trial on my case, guaranteeing me future medical care and medication FOR LIFE. Despite this, I am STILL getting denials, refusals and delays that are costing me dearly in the terms of my general health.