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California WC IMR Volume & Outcomes Held Steady in Q1 2018

Oakland - Data on California workers’ compensation independent medical review (IMR) decisions issued in the first quarter of this year shows that the medical dispute resolution process established as part of  the 2012 workers’ comp reforms continues to produce consistent outcomes, with little change in the number of IMR determination letters and decisions; the percentage of modified or denied treatment requests that are upheld; the types of treatment requests reviewed; and the small number of physicians who are linked to a majority of the disputed medical service requests.    

The latest IMR results come from a California Workers’ Compensation Institute (CWCI) review of IMR decision letters issued in the first three months of this year in response to applications sent to the state Division of Workers’ Compensation after a utilization review (UR) physician modified or denied a medical service requested for an injured worker. California requires workers’ comp claims administrators to have a UR program to assure that care provided to injured workers is backed by clinical evidence outlined in medical guidelines adopted by the state. Most treatment requests are approved by UR, but six years ago state lawmakers adopted IMR to allow injured workers to get an independent medical review of treatment requests that UR physicians determine are not medically necessary.

For the first quarter of 2018, CWCI tallied 42,966 IMR letters rendering decisions on 78,439 primary medical service requests, which nearly matched the 42,949 IMR letters and the 78,861 service requests from the first quarter of 2017. The Institute’s review of the first quarter IMR decisions found that after examining the medical records and information provided in support of a disputed request, IMR doctors upheld the UR determination 90.6% of the time, while in 9.4% of the cases they deemed the service medically necessary and overturned the UR decision. That uphold rate nearly matched the 91.2% rate noted for IMRs from the two prior years, and just as in each of the five years since the IMR process began in 2013, pharmaceutical requests represented almost half of the IMR decisions in the first quarter of 2018. As in the past, requests for opioids were the most common pharmaceutical request submitted for IMR, accounting for 31.0% of all prescription drug IMRs in the first quarter, even though in 91.1% of the IMRs involving opioids, the UR modification or denial was upheld. Those percentages could change in the future, as most of the first quarter IMRs involved UR decisions from 2017, prior to the January 1 implementation of the workers’ compensation prescription drug formulary and regulations, which set new limits and rules for prescribing opioids to injured workers in California. The latest results also show that compound drugs represent a dwindling share of the prescription drug IMRs, accounting for just 2.1% of the pharmaceutical IMRs in the first quarter, down from 4.2% in 2017 and 8.1% in 2015, a decline that may be linked to the 98% uphold rate for compound drug denials and modifications submitted to IMR. In addition to the prescription drug IMRs, the first quarter IMR data show that requests for physical therapy; injections; and durable medical equipment, prosthetics, orthotics, and supplies; and MRI/CT/and PET scans were again the most common types of services submitted for IMR, though the uphold rates for the UR denials and modifications of these services ranged from 89.1% to 93.1%.    

As in prior results, the latest IMR data also showed that a small number of physicians continued to account for a disproportionate share of the disputed medical services submitted for IMR. Reviewing IMR letters sent from April 2017 through March 2018, CWCI found that the top 1% of requesting physicians listed in those letters during that 12-month span (117 providers) accounted for 44% of the disputed service requests, while the top 10 percent (1,169 providers) accounted for 85% of the disputed service requests.