There’s 10 docs in LA who account for 1 of every 8 IMR requests in California’s work comp system.
That’s about 3 for every working day for each physician. That’s a shipload of IMR respects.
According to research just released by CWCI, 88.5% of their requests to overturn a UR decision are rejected.
One wonders if they find something new to appeal each and every time, for surely they must know that if drug A has been rejected 10 times out of 10 – or 20 out of 20, or, well, you get my drift – it probably makes no sense to ask for it again.
Unless, you’re just trying to flood the IMR system, choke it with requests so it can’t function, and pick out one or two screw-ups to hold up as evidence that the entire system is broken. Conveniently ignoring that the flood of unnecessary requests may have played a big role in screwing up that system.
Then you complain that decisions are delayed and late and not fulfilled, conveniently ignoring that most of those delays are due to a failure on your part to send in the right documents.
But let’s set aside these disagreements and focus on what’s really happening here.
We all know that many treatments hurt patients; unneeded surgery, too many MRIs, the wrong drugs or overuse of opioids do much harm. That’s been so well documented you don’t need me to provide citations.
Yet a handful of docs persist in demanding they be allowed to do this to their patients – to overprescribe opioids, to over-radiate, to cut and sew.
Drugs account for almost half of all IMR requests – the vast majority of the denied drug requests are for opioids, a drug class long known to be dangerous, subject to abuse, and rarely appropriate except for short term treatment of trauma or post-surgical pain.
Let’s have a conversation about the human cost of this unnecessary and dangerous treatment. We’ve heard a lot about the harm caused by payers and processes that fail patients – some of it has been accurate and some wildly distorted (the denial of spinal fusion, for one)
What does this mean for you?
For those who tout themselves as claimant advocates, are you ready to talk about over-treatment and the damage it causes and what you will do to protect your clients?
If not, why not?
Good morning, Joe. The age old question is still relevant, why are the masses [AMA] not policing their uninformed members, who either not keeping up with the medical research or just don’t care. Also where are the State Licensing Boards and the DEA? What happened to the promise THEY made to the public “TO DO NO HARM”
Given where we are at today with the broad use of opioids in or society and the devastation it has wreaked on injured workers and costs to the systems; you have to wonder if the individuals at the FDA responsible for permitting off label use of these drugs sleep well at night.
What about Chubb ace
Tim – thanks for the comment. I briefly discussed the transaction last week in the Thursday catch-up post.
cheers Joe
Curious to see if any insurance companies have very high imr rates, or at least outside the norms of their peers or market share. Interesting how the only information to ever come from these reports are based on bad doctors. Isn’t it a little interesting as well, if you remove the 10 bad docs from the LA area, the rest of the numbers are in line or below the norm for SoCal? Why is this never mentioned? Here’s an idea, identify the ten misfits and instead of trying to bust them, maybe, have the insurance companies educate them on what they’re missing, or vice versa.
John -thanks for the comment. A couple observations.
your point about individual insurance companies/TPAs is a good one; not sure if that information is available but it would be interesting to see how the companies stack up. Of course, would have to correct for geographic/physician concentration.
re the “the only information to ever come from these reports are based on bad doctors”, not sure that’s what the report shows. I’d suggest what we see is that the UR process is working in that the vast majority of UR determinations are upheld. That is the key takeaway.
What is clear is that a small subset of docs (as you note) are responsible for a big chunk of the appeals, and likely a big chunk of bad care as well. That seems pretty obvious; if you read the detailed report that point is made.
re identifying the bad docs in public, I’d guess that is a violation of some kind – but that’s just a guess. BTW, I don’t think there are ONLY 10 “misfits” – these are just the most egregious offenders.