Do Your Job, Then I Don't Have to Do Mine

An interesting thing is coming out of Independent Medical Review in California: information that should prevent medical disputes from getting to IMR in the first place, and improve medical treatment standards.

Tom Naughton, vice president of Maximus, the medical review company that has contracted with the state for IMR under SB 863, told the audience yesterday at the California Coalition on Workers’ Compensation 11th annual Conference that one of the most important things that IMR will do is educate California’s workers’ compensation community about patterns involving certain procedures and diagnostic tests.

Naughton said Maximus is gathering data about the IMR requests that it is processing and plans to report any trends that it identifies to the state.

Citing an example about routine rejection of bariatric surgery requests by group health plans, and those rejections being overturned by IMR, Naughton said that the health plans changed their policies so those disputes are rarely seen.

“Where we’re able to identify a pattern of practice either of cases that are going to be upheld always or overturned always −we work with that to educate people,” he said. “That’s what we’re going to do with the IMR here, as well. It’s not just about making the decisions.”

In addition to reducing the quantity of challenged medical requests (and thus speeding up treatment of injured workers) Naughton said that Maximus is continuously updating its procedures because it is constantly looking at medical journals for the most up-to-date studies.

This information is then relayed to the Division of Workers' Compensation so that the state's Medical Treatment Utilization Schedule can remain up to date.

The potential benefit is that the IMR program can help cut down on the percentage of workers’ compensation dollars that are spent on medical cost-containment programs.

I sat as part of the Blogger's Panel at the conference, chaired by Marsh's Mark Walls (founder of the popular Work Comp Analysis LinkedIn group). Participating along with me were Roberto Ceniceros, Senior Editor, Business Insurance magazine, applicant attorney and LexisNexis author Robert Rassp, and Rebecca Shafer, President, Amaxx Risk Solutions, and author of the ReduceYourWorkersComp blog.

Though we went through various issues and prognostications about workers' compensation in California, there was one very poignant comment made by Rassp that I think gets to the heart of Naughton's observations.

To paraphrase Rassp, "If you do your job, I don't have to do mine."

IMR may very well work out to reduce the number of treatment disputes, and may very well improve treatment outcomes.

But only if the behavior of those of us on the front lines change, and only if the information that comes out of IMR is utilized properly by the payer community and the state to improve rules, regulations and procedures.

There will be an education period - I have cited in the past IMR Decision 13-35 where UR denial of a Salonpas patch was overruled by Maximus. The patches sell for $10 online and can be picked up in retail stores for about $15. However the employer will end up paying for the requested medication, as well as the $350 cost for utilization review and another $560 for IMR.

More than likely, the only reason this $15 treatment was subjected to $910 of "cost containment" services was because of some claims department policy essentially mandating UR on every treatment request.

Or it was just easier for the claims examiner to automatically send the request to UR.

Regardless - behavior needs to change in order to realize the potential benefits of the program. Otherwise, IMR just becomes yet another part of "cost containment" bloat.