Calif. medical review decisions on pace for 4th consecutive decrease

If the volume of independent medical review decision letters issued through the first half of 2022 holds for the rest of the year, determinations on disputed medical treatments in California’s workers compensation system would fall for a fourth consecutive year.

Ray Meister, Division of Workers’ Compensation executive medical director, said during a Commission on Health and Safety and Workers’ Compensation meeting Thursday that 62,859 IMR decision letters were issued from January through June. If that pace holds for the last six months of 2022, it would result in a little more than 125,700 decisions for the year.

Data Mr. Meister presented show a steady increase in IMR decision letters from 143,840 in 2014, the first year all medical treatment disputes were eligible for the administrative resolution process created by new state law, to a high of 184,733 in 2018.

IMR volume fell to 163,755 in 2019 to 136,740 in 2020 and to 133,430 in 2021.

Mr. Meister credited a feedback loop for helping drive down the number of IMR disputes, as well as the addition of a prescription drug formulary to the Medical Treatment Utilization Schedule.

“Providers, through the (utilization review) and IMR process, perhaps learn about what the recommendations are and what will be approved as consistent with the guidelines,” he said. “We think another factor is likely the formulary and the MTUS drug list, which went into place in 2018. There’s always a large percentage of the IMR decisions which involve medications, and those numbers have been coming down.”

Mr. Meister said IMR continues to uphold about 92% of disputed utilization review decisions. Mr. Meister also shared updated figures showing a short-lived bump in the number of qualified medical evaluators. The number of QMEs increased to 2,545 in 2021 from 2,480 in 2020 before dropping to 2,440 in 2022.

The division has a sufficient number of QMEs for some specialties such as orthopedics, but for others, it doesn’t have enough providers to generate a panel, he said.

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