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Overview: California independent medical review process

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Recently there has been a lot of discussion – in the media and throughout the industry – about the California independent medical review (IMR) process. Introduced to the workers’ compensation system in California as part of Senate Bill 863, IMR serves as a way to fortify utilization review (UR) decisions and reduce frictional allocated loss adjustment costs. A similar process has been used for more a decade in the group health arena. IMR offers the injured worker a sole remedy for contesting a UR denial. A physician, rather than an administrative law judge, evaluates medical guidelines to determine if the UR was conducted properly.

Since the injured worker can request IMR for each UR denial, the demand proved to be greater than what the state of California originally anticipated. Since its inception in July 2013, more than 315,000 IMR requests have been made for all dates of loss industry-wide. Sedgwick receives approximately 2,000 IMR requests each month from injured workers. Maximus, the contractor for the state of California, has been working to keep up with the demand. Early in the process, they were completely overwhelmed and as a result IMRs took longer than the 30-day turnaround time required in the statute. Maximus has recently ramped up its operations and asserts that it can keep up with the heavy demand.

Across our industry, most IMR determinations currently uphold the original UR denials; this is in stark contrast to the days before the inception of IMR, when most UR denials contested by injured workers were ultimately overturned by judges or agreed/qualified medical evaluators through an often prolonged, expensive and litigious process. In large part thanks to IMR, employers and carriers can successfully uphold the denial of inappropriate medical care. The largest piece of the IMR pie – nearly 45% – relates to decisions about medications. About 86% of IMR decisions uphold the original UR determinations.

A number of plaintiff attorneys in California are attempting to discredit IMR as unconstitutional on the grounds that it removes the judicial branch from the process. They argue that UR and IMR serve to deny necessary care to injured employees. Recent studies show that more than 94% of requested medical treatments requested in California are approved; only 5.9% of requests become eligible for the IMR process.

Sedgwick has prepared a resource document outlining the IMR process and including statistics regarding the demand for and results of IMR. If you have questions or comments, please feel free to post them here or contact me.

Eddy Canavan, VP, Workers’ Compensation Practice & Compliance

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