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Independent medical reviews rising for California comp claims


The number of independent medical reviews for California workers compensation claims rose 19% year-over-year in 2015, despite the fact that doctors conducting such reviews tended to uphold the vast majority of medical decisions made in workers comp utilization reviews, according to a study from the California Workers' Compensation Institute.

California workers comp reforms implemented in 2013 allowed employers to request independent medical reviews conducted by physicians to resolve disputes that arose from utilization reviews over the medical treatment of injured workers. Injuries that occurred on or after Jan. 1, 2013, now are adjudicated using the independent medical review process.

The Oakland, California-based institute said in a report released Thursday that there were 163,826 independent medical review determinations issued in 2015. That's up from 137,761 independent medical reviews in 2014.

Analysis of independent medical reviews showed that independent medical reviewers upheld treatment modifications or denials in 88.6% of cases in 2015, compared with 91% of cases in 2014, the CWCI said. Most of the disputes being considered in independent reviews involved prescription drugs, physical therapy, durable medical equipment, injections and MRI/CT/PET scans.

“Although state lawmakers who enacted IMR expected that the number of disputed treatment requests would decline as doctors, attorneys and others involved in the process became familiar with the types of services that would meet the evidence-based medicine standards and be approved through (utilization review) and (independent medical reviews), the latest data show that after two years, (independent medical review) volume remains high,” the CWCI said in a statement Thursday.

The CWCI said in a report early this month that it's too early to tell whether independent medical reviews will be able to reverse a trend of rising medical-legal costs in California.

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