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Workers comp reviews worth a try


While the jury is out on whether independent medical reviews are working to reduce workers compensation medical costs in California, a recent decision by the California Supreme Court could give comp payers time to weigh the effectiveness of the review process and make tweaks to the system, if needed.

The California high court declined this month to consider a case that argued that independent medical reviews are unconstitutional, effectively upholding a lower court decision upholding independent reviews for California comp claims. Independent medical reviews, established under a 2012 California workers comp reform law, allow injured workers or physicians to appeal medical treatment denials or modifications by workers comp claim payers to an independent review service provider.

So far it appears that independent medical reviews have been crucial for upholding decisions by insurers or employers to deny the use of certain medications, such as opioids, or medical treatments, according to recent analysis from the California Workers' Compensation Institute.

For instance, nearly half of independent medical reviews conducted involved decisions to modify or deny pharmaceutical treatments for injured workers, according to the CWCI. Of those reviews, nearly 90% of independent reviews upheld those medication modifications or denials.

Although independent reviews seem to be reaffirming treatment decisions that already have been made by workers comp claim payers, review proponents say the independently conducted reviews show insurers are approaching medical care for injured workers responsibly.

While insurers and employers see independent medical reviews corroborating their treatment decisions, it seems that injured workers also would benefit from having their claims reviewed by an outside party if their medical treatment isn't being handled properly.

Still, it remains to be seen whether independent medical reviews will hold down costs for California workers comp claims. The Oakland, California-based CWCI said in a separate report that data about independent medical reviews is “too green” to determine whether such reviews can help reduce a trend of increased medical-legal costs for California workers comp claims in recent years.

Meanwhile, some comp observers say the rising number of independent medical reviews is increasing claim administration costs, since employers and insurers pay for reviews.

As more data is gathered, it will be important for stakeholders to find ways to make sure that reviews don't become another cost driver in the California comp system.