In September 2012, Governor Brown signed into legislation Senate Bill (SB) 863. This reform of the workers’ compensation system in California included Independent Medical Review (IMR), which went into effect January 1, 2013. The program is now in its seventh year.
The Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) have posted a progress report on the Department’s Independent Medical Review (IMR) program.
In 2018, the Independent Medical Review Organization (IMRO) processed 252,565 applications, a slight increase from 2017. Of those, 74% (185,783) were determined to be eligible for review.
Concurrently, the IMRO issued 184,733 IMR determinations, a 7% rise from the prior year. At the end of 2017, the average length of time the IMRO took to issue a determination, after the receipt of all necessary medical records, was fourteen days. By the end of 2018, this decreased to a monthly average of nine days.
Overall, the IMRO overturned 10.3% of the utilization review decisions that denied treatment requests made by physicians treating injured workers. Analysis of several variables, including the geographic region of the injured worker, the time elapsed since the worker’s occupational injury occurred, and representation by an attorney or other entity acting on behalf of the worker, shows similar rates of overturned case decisions.
The highest number of requests was for pharmaceuticals, which comprise 42% of the issues in dispute, with opioids the most common drug class (33% of drug requests). As in previous years, the second- and third-highest number of requests were for diagnostic tests (e.g. imaging, radiology) (16% of requests) and rehabilitation services (e.g., physical therapy, chiropractic) (15%).
The treatment request denials that were overturned most often were for behavioral and mental health services (22% overturned) and evaluation and management, which include specialist consultations and dental services (18% overturned).
Changes in the Medical Treatment Utilization Schedule (MTUS) that took effect in 2018 include the new drug formulary and the update of several evidence-based guidelines. Expert reviewers for IMR apply these guidelines to their evaluations of medical necessity, citing the Chronic Pain, Low Back Disorders, and Opioid Guidelines most often.