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A new analysis of independent medical review decisions issued in 2014 suggests that the medical dispute resolution process mandated by the workers’ compensation reform bill enacted in 2012 is working to assure that the treatment provided to California injured worker meets evidence-based medicine standards while providing a needed check against unnecessary and potentially harmful tests, surgeries, drugs and procedures.
The CWCI study used data from 137,781 independent medical review (IMR) determination letters issued in 2014 in response to applications submitted to the state after a utilization review (UR) physician modified or denied a requested medical service. State law requires workers’ compensation claims administrators to have a UR program overseen by a medical director to assure that treatment given to injured workers is supported by clinical evidence outlined in medical guidelines adopted by the state. While most treatment is approved by UR, three years ago state lawmakers adopted IMR to allow injured workers a chance to get a second, independent medical opinion on the estimated 6 percent of medical service requests that are deemed not medically necessary by a UR physician.
A review of the IMR decisions issued last year shows that after reviewing the patient’s records and any additional information provided in support of the request, independent reviewers agreed with the UR doctor’s modification or denial of the service 91 percent of the time, while in 9 percent of the cases the IMR doctor overturned the UR decision. Prescription meds, including compound drugs and opioids, were by far the most common type of treatment submitted for IMR, accounting for 45 percent of the decisions rendered last year, with the UR denial or modification upheld in 92 percent of the prescription drug IMRs. Durable medical equipment, physical therapy, injections and diagnostic tests and measurements rounded out the top 5 types of treatment that were reviewed, with the independent reviewer agreeing that these services were not medically necessary in 88 to 94 percent of the cases.
In addition to identifying the types of services submitted for IMR and the number and percentage that were upheld, the analysis also reveals that a relatively small number of physicians account for the majority of the disputed medical services, with the top 10 percent of physicians who were named in IMR decision letters (1,332 providers) accounting for 83 percent of the IMR requests. Half of the independent medical review determinations issued in 2014 involved treatment requests for workers injured prior to 2010, but the year of injury did not impact the rate at which the UR decisions were upheld by an independent medical review physician.
The Institute has included more analyses, tables and findings from the study in a Research Update report, “Independent Medical Review Outcomes in California Workers’ Compensation,” which is posted in the research section of its website, www.cwci.org.