June 2, 2016
CWCI Finds Consistent Outcomes in California WC Independent Medical Reviews
A new analysis of California workers’ compensation independent medical review (IMR) decisions issued in the first quarter of 2016 shows that the medical dispute resolution process mandated by the 2012 workers’ comp reform bill is yielding consistent results in terms of the number of IMR determinations, the percentage of modified or denied treatment requests that are upheld, the types of medical services that are reviewed, and the small number of physicians who continue to account for a disproportionate share of the disputed medical service requests.
The analysis by the California Workers’ Compensation Institute (CWCI) tallied 40,742 IMR decision letters issued in the first quarter of this year in response to applications submitted to the state after a utilization review (UR) physician modified or denied a medical service requested for an injured worker. Under state law, workers’ comp claims administrators must have a UR program overseen by a medical director to assure that care provided to injured workers is backed by clinical evidence outlined in medical guidelines adopted by the state. Most treatment is approved by UR, but in 2012 legislators adopted IMR to give injured workers a chance to get an independent medical opinion on the estimated 6% of treatment requests that UR physicians deem not medically necessary.
The data on IMR decisions issued from January through March of this year show that after reviewing the patient’s records and any other information provided in support of the request, independent reviewers agreed with the UR doctor’s modification or denial of the service 88.8% of the time, while in the balance of the cases the IMR doctor approved the request. That result is consistent with the 88.6% uphold rate recorded in 2015, and the 91% uphold rate for IMR decisions from 2013-2014. Likewise, as in the 2013-2015 results, requests for prescription drugs continued to account for nearly half of all IMR decisions in the first quarter of 2016. Once again, opioid painkillers and compounded drugs together accounted for about 40% of the first quarter prescription drug IMRs, even though the IMR uphold rate for UR doctors’ modifications or denials of such requests have exceeded 90% ever since IMR took effect. Beyond pharmaceuticals, the first quarter data show requests for physical therapy, durable medical equipment and injections remained near the top of the list of disputed medical services that undergo IMR, though as in the past, IMR physicians found the services were not medically necessary about 90% of the time.
The first quarter results also confirmed prior findings which showed a relatively small number of physicians continue to account for a majority of the disputed medical services, with the top 10% of physicians who were named in the first quarter IMR decision letters (553 providers) accounting for 76% of the IMR requests, while the top 1% of medical providers (56 individuals) accounted for 31% of the disputed services.
Additional details and graphics from the study are available in a CWCI Spotlight Report, “1st Quarter 2016 IMR Outcomes,” which is posted under Research at www.cwci.org.