Workers' Compensation

California: Utilization Review and Independent Medical Review Best Practices

Loosening the rope on the UR/IMR Gordian Knot

Karen C. Yotis, Esq., Feature Resident Columnist of the LexisNexis Workers’ Compensation eNewsletter, provides insights into workplace issues and the nuts and bolts of the workers' comp world.

While UR and IMR continue to generate controversy (witness Dubon and its seemingly endless progeny), the California workers’ compensation community is still trying to make sense of UR/IMR and learn how to incorporate the basic process into their practice.

Anticipating significant interest around the ins and outs of this shape shifting topic, the Division of Workers’ Compensation hosted at its recent 22nd Annual Education Conference an SRO session titled “Utilization Review (UR) and Independent Medical Review (IMR)” presented by George P. Parisotto, an attorney from California’s Department of Industrial Relations, and Rob Nydam, J.D., Director of Operations at MAXIMUS Federal Services. Parisotto works out of the DWC, and MAXIMUS is, of course, the independent medical review outfit that the DWC has designated to conduct all IMR in California, so the information and best practice tidbits coming from these speakers considerably loosened the rope on the UR/IMR Gordian Knot.

Not as Big and Bad as All That

Before getting into the nuts and bolts of UR/IMR, Nydam took pains to correct the misconception of how big IMR really is. To clarify what he called “the single most misleading statistic about IMR,” namely that roughly 20,000+ new IMR applications were received for each month during 2014, Nydam did some quick math. He first separated new applications from unique applications (there is a serious dupe problem) and then diluted the ‘unique/new’ number of approximately 15,000 down to ‘eligible’ applications, which are somewhere in the range of 12,000 per month. This is the number of unique, eligible IMR applications that MAXIMUS is now receiving on a monthly basis, which is the consistent amount that Nydam expects for the foreseeable future.

Nydam also downplayed the depth of the current backlog of 2014 IMR applications. Admitting that the initial application volume was four to five times higher than what anyone expected (the backlog numbers climbed from 5000 in January 2014 to almost 25,000 throughout the Fall of 2014) Nydam explained that MAXIMUS spent most of 2014 working off the 2013 requests. Irrespective of the backlog peak exhibited in September and October, going forward Nydam expects to see figures in line with the November/December 2014 number of 12,000 backlogged applications, as well as a more even line across the board in the graph for next year’s UR/IMR session.

Nydam also mentioned the request for medical records as one of the last remaining pieces in the UR/IMR process that needs to undergo significant improvement. MAXIMUS continues to consult with a cross-section of industry experts to improve the submission protocols and Nydam invited feedback about altering the records submission process to make it smoother and more streamlined for everyone.

The Devil and his UR/IMR Details

In addition to sharing these reveals, the speakers clarified many of the minute details of UR/IMR, paying particular attention to:

> the steps in the UR/IMR process (submission, initial approval, review and final decision all within five days);

> the specifics involved in completing the Utilization Review/Request for Authorization Form (DWC and MAXIMUX are seeking feedback as part of their plan to change forms over the course of the next year);

> UR timelines (given Dubon II, the speakers recommend a quick review of timelines)

> UR liability disputes (raise this issue as soon as possible to save everyone’s time and energy);

> UR internal appeals (UR organizations can expect the DWC to take a closer look during its regular audits at how well UR decision letters are explaining the internal appeals process);

> IMR eligibility;

> IMR determinations (most claims come out of Los Angeles, pharmaceuticals, physical therapy and then surgery take up most of the IMR process, and reviewers adhere for the most part to the Medical Treatment Utilization Schedule or MTUS);

> IMR appeals (there are limited grounds and the medical necessity finding cannot be appealed); and

> IMR penalties (MAXIMUS and the DWC are in the process of developing a first order to show cause why certain identified claims administrators are not following through on their IMR obligations).

In addition, the speakers reviewed top cases, focusing for the most part on Dubon and its seemingly endless progeny. However, they were not in a position to discuss McFarland v. The Permanente Medical Group, a potentially game-changing decision scooped in this e-newsletter just as the DWC’s education conference was getting under way.

Practical Pointers for Providers

One of the more noteworthy highlights of the session were Parisotto’s recommendations for providers. He couldn’t have been more simple and clear when he advised providers to:

> Use evidence-based medicine for treatment course;

> Follow the Medical Treatment Utilization Schedule (MTUS) guidelines;

> Complete the RFA or an accepted equivalent;

> Provide a full explanation for requested treatments;

> Submit literature-based evidence to justify recommendations if going outside MTUS;

> Educate patients on treatment options and the effects of various treatments;

> Be available for peer-to-peer UR discussions.

IMR Tips and Tricks

Nydam also shared five practice pointers that address major issues and concerns for IMR today that were culled from his experience engaging with the California workers’ compensation community.

First—and this is a big one for applicants and their attorneys—no more “Notice to Injured Worker” letters will be sent about things like missing signatures, incomplete applications without UR determinations attached, etc. Now that MAXIMUS is one year into the IMR program and believes that it has most of the kinks worked out, any application with a procedural defect will go straight to the WCAB for an eligibility determination. Defects can, however, still be cured if an application is resubmitted within the appropriate timeframe.

Second is a new development that relates to all parties and is part of a solution for the frustration that surrounds the submission of medical records for IMR. Nydam directed everyone to use the new Bar Code Cover Sheets with their Notice of Assignment and Request for Information (NOARFI). By placing a copy of this bar code cover sheet on top of submitted medical records whenever possible (especially if submitting by fax) everyone can be sure that the records they are submitting will be properly routed.

Third—and this seems like a no brainer, but it’s a significant problem with respect to IMR eligibility determinations—is to be certain that both applicants AND their attorneys sign their respective forms. The crux of the concern lies not so much with unsigned representative forms but with unsigned applications, since the app includes a release of medical records. No worker signature on the app means no medical records, it’s as simple (and as problematic) as that.

Fourth is to submit a copy of the application from the claims administrator that comes with your UR decision. If your app doesn’t include the data that is provided by the C/A, your correspondence might be misdirected, the IMR process could be delayed, or the IMR application request might be deemed ineligible. This small step will go a long way towards preventing delay issues and ensuring that your information remains secure.

Last, but certainly not least, is the admonition to avoid submitting duplicate requests. Let me say this again . . . One. Time. Only. Duplicate applications created a huge amount of frustration during the height of the IMR backlog in September/October of 2014 and are more likely to cause delay than make the process move faster. Contact MAXIMUS directly to confirm receipt of your application.

The UR/IMR Crystal Ball

The speakers wrapped up their insiders’ review of UR/IMR with eye towards the future. According to Nydam, the focus for UR/IMR in 2015 will be on refining the working process, particularly with respect to the filing of electronic applications, instituting an option for electronic correspondence, and ensuring the security of electronic data exchanges between the parties. Nydam stated:

“Obviously bad data frustrates the IMR process and the receipt of data from a primary source will be a huge boon to the reliability and smooth operation of IMR.”

In addition to improving data integrity and streamlining the submission process, these anticipated digital enhancements to the process will also give all parties in a workers’ compensation claim better overall access. The ability to log in, check a case status, update contact information and upload documents doesn’t currently exist and MAXIMUS is actively working with the DWC and claims administrators to further automate the IMR process. Nydam clearly welcomed additional input from the community on how to improve and streamline the process.

The speakers also provided this list of resources that readers should find helpful:

> Independent Medical Review – http://www.dir.ca.gov/dwc/IMR.htm

> Frequently Asked Questions – http://www.dir.ca.gov/dwc/IMR/IMR_FAQs.htm

> Regulations – http://www.dir.ca.gov/dwc/DWCPropRegs/IMR/IMR_Regs.htm

> Forms – http://www.dir.ca.gov/dwc/forms.html

> DWC Medical Unit – http://www.dir.ca.gov/dwc/MedicalUnit/imchp.html

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