Independent medical reviews fall in 2020 in California
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The number of workers compensation claims requiring an independent medical review have fallen to an all-time low, according to a study released Thursday by the California Workers Compensation Institute.
The Oakland-based institute reviewed more than 1.1. million IMR decision letters issued from 2014 to 2020, finding that the use of IMR to resolve comp medical disputes climbed to a record high of 184,000 in 2018, but declined in 2019 to 163,000 and fell to an all-time low of 136,000 in 2020. CWCI said the low overall claim volume from pandemic-related shutdowns and the adoption of an evidence-based drug formulary also impacted IMR usage.
The formulary, which was adopted in 2018 and established categories of drugs exempt from utilization review, led to the use of IMR in prescription drug disputes to fall from 46.4% of all IMR disputes in 2018 to 39.1% of all disputes in 2020. The mix of services submitted for IMR has also changed, with review requests increasing 1.5% to 2% in the past two years for physical therapy, injections, durable medical equipment, prosthetics, orthotics and supplies, according to the report.
Outcomes from IMR remained stable, with IMR physicians upholding a doctor’s modification or denial of services 90% of the time in 2020, compared to 88% of the time in 2019.
CWCI also noted that, as in prior studies, a small number of physicians continued to drive much of the IMR activity, with the top 1% of requesting physicians — just 89 doctors — accounting for 39.8% of the disputed service requests that underwent IMR in 2020. The top 10 individual physicians alone accounting for 10.2% of the disputed requests, and the study found that seven of the top 10 physicians in 2020 were also on the top 10 list for 2019.
More insurance and workers compensation news on the coronavirus crisis here.
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California independent medical reviews hit new high
The number of independent medical review determination letters calling for review of treatment denials and modifications issued in California peaked to 184,733 in 2018, 7.3% more than in 2017 and 28.4% more than in 2014, when the California Workers’ Compensation Research Institute starting tracking them to study the review process.
