Follow-up: Maximus Notices of IMR Assignment & Request for Information

As a follow-up to our October 18 Executive Memo on the deficient Notices of IMR Assignment & Request for Information, we want to alert you to the free 2-hour webinar scheduled for Tuesday, Nov. 5 from 10 a.m. to noon in which DWC and Maximus will discuss the IMR process and a working concept for a planned IMR electronic submission feature, and address questions on the IMR process. Space is limited and pre-registration (https://www3.gotomeeting.com/register/638211878) is required to attend this free webinar, which will use the GoToMeeting web platform so claims administrators across the country can attend provided they have a suitable computer and web access. Questions must be submitted in advance to LouWShields@maximus.com no later than tomorrow, Friday, Nov. 1.

In the past week, claims administrators from throughout the community have reported the following inventory of IMR-related issues to us:

• Multiple notices (up to several hundred) are being sent to claims administrators in a single envelope with no postmark, only a typed-in date above the address label.
• Envelopes include Acknowledgements of Requests for Independent Medical Review, Notices of Assignment and Requests for Information mixed in with IMR Determinations, all with different dates.
• Recent notices are untimely and lack all the required information noted in CCR §9792.10.4 (b), (c) and (d) which is needed to respond to the request, including:
o the identification of the disputed treatment;
o the date of the request for authorization;
o the name of the requesting physician;
o the date of the claims administrator’s UR decision;
o the date Maximus received the IMR Application (DWC Form IMR);
o an indication of whether IMR will be done on a regular or expedited basis.
Many claims involve multiple UR determinations, so claims administrators are unable to submit the records requested unless Maximus notifies them which determination is disputed. One claims administrator has begun sending all medical records on their claims just to avoid missing the deadline. Another is objecting and returning them to Maximus.
• Maximus has claimed that claims administrators have failed to submit requested medical records when, in fact, they have been submitted • Acknowledgements of Requests for Independent Medical Review have included requests for copies of the UR decision when they weren’t submitted with the IMR Application. Not only does this shift that burden from the applicant to the claims administrator, any application sent to DWC without a copy of the UR decision should have been deemed incomplete and ineligible for review by the Administrative Director.
• Claims administrators who are receiving hundreds of incomplete requests for information have been told that Maximus will not send corrected notices and that they must continue to call Maximus to obtain the missing information. This has jammed the Maximus phones, making it very difficult to get through. When claims administrators have been able to get through on the phone, in some cases Maximus has refused to provide the requested information, while in others, Maximus has told the claims administrators that its policy is now to provide information on only 2 claims per call.
• Few IMR determinations have been issued, and many of those that have issued have not met the 30-day timeframe required under LC §9792.10.6(g)(1).
• A member reports that Maximus is no longer honoring the preferred method of contact on file with Maximus and will only send communications by mail to the address submitted on the IMR application.
• Maximus refused to terminate an IMR upon request of a claims administrator, stating that only a claimant or applicant attorney can stop the IMR process. This is contrary to CCR 9792.10.6(a) which allows IMR to be terminated at any time upon the claims administrator’s written authorization of all disputed treatment.

If you have encountered additional problems, please let me know, as the Institute is interested in seeing that the cost-saving elements of SB 863, including IMR, are successful. We will continue to compile and forward such information to the Division and will work toward practical solutions to these and other issues that may arise.

We have already sent inquiries to both the DWC and Maximus Federal Services in an effort to help resolve the problems and make the IMR process run more smoothly, and we will advise you when we receive responses to those inquiries. In addition, some of these issues may be addressed by the DWC and Maximus in next week’s webinar, so we urge you to register. In the meantime, if you have received additional information on these or related matters from the DWC or Maximus, please keep us posted.

BR/by