Independent Medical Review – Hidden New Costs to Policyholders?

Independent Medical Review (IMR) was created as part of California Senate Bill 863, which is attempting to reform worker’s compensation law in California. One of the new regulations part of this bill is called Independent Medical Review (IMR). IMR is a process available to injured workers who are dissatisfied with utilization review (UR) decisions in workers’ compensation cases.

As of July 1, 2013, all dates of injury for California workers’ will use an IMR and all disputes will now be resolved by a physician or panel of physicians rather than going through the costly court system. Seemingly a positive service provided to the injured workers, is there a hidden catch?

Who Pays?

The injured worker requesting the IMR does not pay for the review process. Instead, the IMR costs will be paid for by the claims administrator, which will then be passed along to the insurance companies and ultimately the policyholders.

WC Webzine provides their questions on the topic: “Given the expense of this new process, it is questioned whether adjusters will authorize inexpensive procedures like physical therapy or a generic medicine, rather than pay upwards of $600 for IMR. Will frustrated workers be more likely to contact attorneys after getting the UR denial and the confusing IMR Application? Only time will tell.”

There is already an increase in IMR submissions as noted by the DWC, who received 589 IMR applications before July 2013 and by August, the IMRO received 15,731 IMR applications by mail and fax.

Why Change The System?

Under the current system, it typically takes nine to 12 months to resolve a dispute over the treatment needed for an injury. These steps include:

  1. Negotiating over selection of an agreed medical evaluator
  2. Obtaining a panel, or list, of state-certified medical evaluators if agreement cannot be reached
  3. Negotiating over the selection of the state-certified medical evaluator
  4. Making an appointment
  5. Waiting the examination
  6. Awaiting the evaluator’s report, and then if the parties still disagree
  7. Awaiting a hearing with a workers’ compensation judge
  8. Awaiting the judge’s decision on the recommended treatment. In many cases, the treating physician may also rebut or request clarification from the medical evaluator, and the medical evaluator may be required to follow up with supplemental reports or answer questions in a deposition.

SB 863 replaces those eight steps with an IMR process similar to group health that takes approximately 40 (or fewer) days to arrive at a determination so that the appropriate treatment can be obtained.

Although the IMR is intended to help the injured worker, the question must be asked who will ultimately pay for this new service.

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