Wednesday, November 28, 2012

IMR/IBR - Cultural Change Doesn't Come Easy

The actuaries said that whether savings will be realized under California's SB 863 is dependent upon regulatory action. The fear of course is that regulations will end up either ineffective or unduly burdensome thus mitigating potential savings due to excess complexity.

California already has one of the most complex workers' compensation regulatory schemes in the United States.

Draft rules for the independent medical review process were just released. Among some of the provisions that are seeing critique are:
  • that claims administrators must provide a year’s worth of medical records for review
  • the absence of any deadline for the administration to request an independent medical review determination
  • the absence of any penalties if the review company fails to issue a timely decision
In addition, the claims administrator must pay the cost of IMR. The proposed fees range from $215 if a carrier elects to authorize a treatment request and terminate IMR before a decision is made to $760 for a regular review and $850 for one conducted by two physicians who hold an M.D. or D.O degree.

The division is working to finalize a contract with Maximum Federal Services Inc. to provide IMR services. The company, headquartered in Reston, Va., currently does group health IMR for the California Department of Managed Health Care.

Some are still complaining about the built in lack of transparency in the IMR process - the fact that under new Labor Code section the decision is made by an anonymous reviewer with no real ability to appeal.

Another complaint seems to be that the regulations don't appear to eliminate the possibility of delays due to inaction at the Administrative Director level. On the one hand, there is no deadline for the division to request an independent medical review. On the other, there is no penalty should the review company miss statutory deadlines.

There is some merit about deadlines on the administration for dealing with IMR requests. Until former Administrative Director Rosa Moran took the job, the wait to getting a panel of QMEs took months and there was a huge backlog. Moran brought the wait time down to several weeks.

Regardless of what the regulations say or do, critics of them completely miss the point: IMR, and its little sister IBR (independent bill review) are complete game changers. The issue is not really what the regulations say or do. The issue is that these processes introduce an entirely new concept to workers' compensation, and completely disrupt a culture that had been developing for over 100 years.

Whether or not there are penalties, whether or not there are time deadlines, whether or not a year's worth of records need to be supplied - what people aren't getting is that IMR is there to encourage people NOT to use it.

Workers' compensation is supposed to be a self-executing administrative system.

The problem that was identified by the authors of SB 863 is that there had become a lack of "self" in the execution part of the system. Carriers weren't approving procedures quickly or timely. Claimants were seeking treatment outside the boundaries of known science.

And the whole treatment process was taking too long, costing too much, and wasting too many resources.

So what if there isn't an appeal? So what if a year's worth or records is too much? So what if the review is anonymous? So what if the carrier has to pay the IMR fees?

When dealing with mechanical or engineering issues, professionals in those fields are taught to take the paths of least resistance so long as the outcome is within tolerance and safety is not compromised.

Ditto with IMR/IBR - the point behind these laws and soon-to-be regulations is that they will encourage path to least resistance behavior. Claimants and their treatment providers will begin to stop challenging UR decisions that are in compliance with guidelines and/or science. Carriers and administrators will start approving treatment requests that are still reasonable even though not necessarily supported by current science.

And yes there will be cases that fall through the cracks where treatment should have been approved but wasn't, or where treatment should not have been approved but was. Those cases are going to be few and far between.

More importantly the parties to a treatment dispute are going to be much more motivated now to resolve differences much more quickly and efficiently.

That's the point. This is a big cultural change and many people don't deal with change well.

And those who don't deal with change well had better either get out of the way or get on board real quick: The Division of Workers’ Compensation plans to implement the proposed rules as emergency regulations, which means the administration has to submit them to the Office of Administrative Law for approval by Dec. 7.

I can't help but be amused at the irony, for it was 71 years ago on that date that Pearl Harbor was attacked provoking the United States into war against Japan.

I'm not making light of Dec. 7, Pearl Harbor, or even suggesting that the IMR process has such historical significance. Dec. 7, though, completely changed the culture of the generation that was about to live through another world war.

Likewise, the culture of California workers' compensation is changing for this current generation.

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