The Independent Medical Review (IMR) program is part of an important essential overhaul of the California Workers’ Compensation System that was created pursuant to Senate Bill (SB) 863.

The IMR program provides an expedient method to resolve medical necessity treatment disputes for work-related injuries occurring on or after Jan. 1, 2013. On July 1, 2013, IMR became available to resolve medical necessity treatment disputes for all dates of work-related injury as long as the requested treatment was denied, delayed, or modified following utilization review after Jan. 1, 2013.

The DWC has contracted with Maximus Federal Services, an independent medical review organization (IMRO), until December 31, 2014 to conduct IMR on its behalf. Maximus contracts with medical professionals to perform the review. The names of the professionals are confidential in communications outside the organization.

All IMR decisions are posted on the DWC website with redacted information. While each IMR request is assigned a number when it is received, the posted IMR decisions are not numbered sequentially because some requests are withdrawn and others determined to be ineligible. Further, some applications have not been assigned yet because DWC is awaiting additional information requested from the parties.

Thus far and informal review of the information posted by the DWC shows that the Maximus professional reviewer sustained the utilization review physicians’ determinations to deny the requested treatment more times than they overturned the UR decisions thus favoring the employer’s point of view.

An analysis of some of these decisions by the California Society of Industrial Medicine and Surgery said that “some Maximus professional reviewers are better than others. In some cases, the professional reviewers performed a thorough review and provided a clear and cogent rationale for their decision. Unfortunately, in other cases, the professional reviewers cited no authority whatsoever to support their decisions.”