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Workers compensation experts say they hope there will be fewer disputes about injured employees' medical treatment now that a California court has ruled the state's independent medical review process is constitutional.
In California, requests for medical treatment go through a utilization review process to ensure treatment is medically necessary before it's approved. Since July 1, 2013, disputes been resolved by physicians through an independent medical review, “rather than through the often cumbersome and costly court system,” according to California's Department of Industrial Relations.
While employers can't challenge treatment that is approved, injured workers can challenge independent medical reviews that deny, delay or modify recommended treatment.
In Frances Stevens v. Workers' Compensation Appeals Board and Outspoken Enterprises Inc., a three-judge panel of California's 1st District Court of Appeal ruled unanimously last week that “California's scheme for evaluating workers' treatment requests is fundamentally fair and affords workers sufficient opportunities to present evidence and be heard.”
Ms. Stevens, who fractured her right foot in October 1997 while working as a magazine editor, was denied a home health aide, Ativan, Flexeril, diolofenac cream and hydrocodone, court records show. She argued that the independent medical review statute violates her rights to due process.
California's independent medical review is good “because it got nonclinical people out of the decision-making process on clinical treatment,” said Mark Pew, senior vice president at PRIUM, a Duluth, Georgia-based medical management company. “There are a lot of states that have judges making decisions on medical issues as presented to them by attorneys.”
Mr. Pew said in some jurisdictions, such as Louisiana, Alabama and Illinois, “people have shied away from doing (utilization review with disputes being settled by judges) because the judges almost always side with injured worker, regardless of what the evidence … says about the appropriateness, or lack thereof, of treatment.”
An April report by the California Workers' Compensation Institute found that the majority of independent medical review requests reviewed last year involved pharmaceuticals, durable medical equipment, physical therapy, injections and diagnostic tests.
The report shows that 91% of all independent medical review decisions upheld the utilization review opinion (see chart). About 10% of physicians accounted for 83% of all disputed treatment requests, according to the report.
The process does add cost to the workers comp system, but the fact that the vast majority of utilization review decisions are upheld means “the system is working,” Mr. Pew said.
According to the Department of Industrial Relations, an independent medical review costs $340 to $520.
Despite the ruling, it's likely some physicians will “continue to flood the system with thousands of requests for (independent medical review), most of them for drugs and procedures that fall far outside the state's evidence-based clinical guidelines,” Joseph Paduda, principal of Madison, Connecticut-based Health Strategy Associates L.L.C., wrote Monday in a blog post on his website.
The hope is that doctors will learn “what is acceptable and what isn't, and needless friction will decrease,” Mr. Paduda wrote.
Some people “may continue to poke at (the process), but I don't see them being successful,” Mr. Pew said. It's better than the previous system and the department “would be taking a serious step backwards if they chose to disassemble (it).”
California insurance experts are optimistic that a new workers compensation prescription drug formulary will help injured workers and reduce comp costs in the state, but the legislation could face hurdles from claimants who need to be weaned from banned drugs or want to continue using them off-label.