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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.
The Oakland-based research organization posted the latest report Monday, showing a steady year-over-year climb in requests for medical reviews with the exception of 2017, which saw a 2.2% decrease.
For the study authors reviewed data from nearly 830,000 IMR determination letters generated by Maximus, the Independent Medical Review Organization contracted by the state to manage the IMR process, from January 2014 through December 2018.
The review process is a mandated oversight used by claims administrators to ensure that the care provided to injured workers meets evidence-based medicine standards for medical necessity, per state law in California.
IMR physicians upheld Utilization Review modifications and denials 88.6% of the time in 2018, down from the 91% uphold rate in 2017. IMR uphold rates by medical service category ranged from 75.8% for evaluation/management services to 92.7% for acupuncture requests, according to the report.
Pharmaceutical requests topped the list of medical services submitted for IMR, representing about 46.3% of the 2018 IMR decisions, per the report. Opioid requests made up 32.3% of the 2018 pharmaceutical IMRs, up from 29.5% in 2017. IMR physicians continued to uphold about 90% of the UR denials and modifications of pharmaceutical requests, including opioid requests.
Other report highlights include:
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.