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California’s dip in independent medical reviews may be temporary

Posted On: Mar. 21, 2018 6:33 AM CST

California’s dip in independent medical reviews may be temporary

The first-ever decline in the number of independent medical reviews in California since it enacted workers compensation reforms might not be the start of a downward trend, but rather an anomaly as providers and injured workers get used to the state’s newly enacted closed drug formulary and medical treatment utilization schedule, experts say.

The volume of independent medical reviews declined by 2.2% in 2017 for the first time since the state adopted its practice of reviewing medical claims for injured workers in 2012, according to a report released March 15 by the Oakland-based California Workers’ Compensation Institute.

“It was a modest decline. As for the future it is hard to know (if the decline will continue) given the significant changes in dispute resolution that are taking effect this year,” said Alex Swedlow, president of the institute, which tallied California Division of Workers’ Compensation data showing 3,808 fewer cases in 2017 than in 2016.

The new figures arrived a month and a half into the state’s inception of a closed drug formulary, which limits new opioid prescriptions for injured workers to four days and calls for a utilization review for refills, among other regulations. The year 2018 also brought in an assortment of new guidelines for medical treatment allowed before a case calls for a utilization review, which comes before an appeal for an independent medical review.

Five years ago, state lawmakers adopted the review standards, anticipating that once doctors, attorneys and others came to know which services could be approved as meeting evidence-based medicine standards, the process would reduce treatment disputes. The new data suggested the review process is working and has helped curb opioid prescribing statewide, according to the institute’s report.

In 2017, 29.1% of requests for independent medical reviews were for opioids, accounting for the largest share of the review requests. Given that opioids are limited under the formulary, experts predict an increase in reviews.

Doctors and attorneys representing injured workers will have to get used to the new parameters for such prescriptions and medical services to ensure a steady decline in reviews, according to Eddy Canavan, Orange, California-based vice president of the workers compensation practice and compliance for Sedgwick Claims Management Services Inc.

“If physicians do not adopt and adhere to the formulary, I don’t see (the number of independent medical reviews) dipping again,” said Mr. Canavan. “We will not see an initial decrease in anything until the physicians can reset.”

“Because California just implemented the closed formulary (the number of independent medical reviews) could kick up again as the treating providers try to get used to the closed formulary along with the changes to the MTUS guidelines,” said Mike Lemrick, Dallas-based vice president of operations, independent medical evaluations and utilization review, for Coventry Workers’ Comp Services. “The formulary raises questions.”

Further study of 648,450 IMR decision letters issued from 2014 through 2017 found that outcomes were unchanged as reviewing physicians again upheld 91.2% of modified or denied medical service requests that they reviewed, the institute revealed.

That’s a sign that doctors and attorneys representing injured workers could continue to back off from requesting the follow-up reviews when the chance of a utilization review decision getting overturned is slight, Mr. Canavan said, adding that he thinks the number of independent reviews could dip again, but not right away.

Mr. Swedlow said the state will not know until the third or fourth quarter whether there’s an uptick in independent medical reviews for 2018.