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California independent medical reviews hit new high

Independent medical review

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:

  • Uphold rates did not vary with the age of the claim, but the mix of services submitted for IMR varied considerably. Among 2018 IMR decisions, pharmaceutical requests represented 26.2% of the IMRs on first-year claims but 61.2% of the IMRs on claims that were at least 11 years old.
  • Of the 2018 numbers, data showed that 95% of the review letters were submitted by attorneys representing injured workers, with the remaining 5% submitted by doctors and the injured workers themselves, according to the report.
  • In 2018, there were 541 law firms that were named in more than 50 IMR determination letters in 2018. The top 10 firms alone accounted for 15% of all IMR volume, the top 25 firms accounted for 25%, and the top 50 firms accounted for 35.4%.
  • A small number of physicians continue to drive a high percentage of IMR requests, with the top 1% of requesting physicians—122 providers—accounting for 44.2% of the disputed service requests that underwent IMR in 2018, and the top 10 individual physicians accounting for 9.5% of the disputed service requests. Seven of the top 10 physicians in 2018 were also on the top 10 list for 2017.
  • In a significant number of IMRs, the requested service was approved by UR, but modified for a lesser quantity than requested to comply with the treatment guidelines. The authors estimated that 7% of pharmaceutical IMRs, 8% of physical therapy IMRs, and 4% of both the chiropractic and acupuncture IMRs were submitted solely on the basis of a reduction in the number of services allowed, even though provision of the initial or trial service was approved.
  • Los Angeles County, the Bay Area, and the Inland Empire/Orange County accounted for two-thirds of the 2018 IMR determination letters. The Bay Area saw the biggest jump in letter volume, with 4,500 more letters in 2018 than in 2017, while San Diego had the biggest percentage increase at 18.3%.



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