Thursday, November 1, 2012

IBR/IMR A Culture Shift Subject to the Test of Time

A good friend of mine brought up a very good point that has been missing from the discussions concerning California's SB 863: the impact of the shift from interaction at the Workers' Compensation Appeals Board District Offices (the Board) to paper reviews.

She makes very legitimate observations.

Under our present system, the insurance company may have underpaid but if the lien claimant is going to drag them down to the Board anyway, why should they bother to double check their figures to make sure they paid properly?

For many attorneys, there is little incentive to resolve billing disputes and eliminate future billing events that require no legal skill, little preparation, and facilitate double and triple billing at the Board.

On the flip side, the provider may have been paid properly, but has nothing to lose from letting a collection agent who is working for a percentage squeeze some more money out of the insurance company by threatening to run up their legal costs. If a $150 lien filing fee is unreasonable, how reasonable is it to have to pay $150 an hour to fight a meritless claim?

I agree with her assessment that independent bill review (IBR) will do away with the inappropriate litigation tactics because there won’t be any more litigation.

This is the way it should be because billing disputes are accounting problems, not legal problems. (Could you imagine a Blue Cross claims adjuster and a pharmacy clerk from CVS going before a Superior Court judge with their $500 dispute? Our medical delivery system would collapse if it were run like workers’ comp.)

She says, "When both sides realize that there’s no longer an incentive to engage in improper collection and payment practices, I predict that the demand for IBR will diminish to the point that it’s mainly being used for $200K hospitalizations and similar bills. One non-monetary advantage that IBR will serve is that if a doctor was truly underpaid, he won’t have to wait years until the case in chief is resolved to get what is owed him. Another one is that the Board and the judges will not have to deal with issues that they are in no way equipped to address."

I think this observation has merit - SB 863 is a seismic cultural shift and is going to be a major change in the ways of business in the workers' compensation claims world.

In the same way that IBR is a cultural shift, so too is independent medical treatment review (IMR).

Let's face it, the general medical examiner in work comp, be it an Agreed Medical Examiner or Qualified Medical Examiner are not experts in the Medical Treatment Utilization Schedule (MTUS) and because of their existing medical practice businesses, getting an opinion about the reasonableness and necessity of medical treatment just takes too long - that promotes extended disability which is the last thing either an employer or employee want.

Likewise, judges lack the medical expertise to determine whether a treatment complies with the MTUS or not.

Much of the resistance to IMR and utilization review (UR) is due to the general myth that injured workers are entitled to whatever treatment Bill Gates would get if he were injured at work. This is simply not true. They’re entitled to the same reasonable medical care that you or I would expect our group carrier to pay for. This does not include unlimited therapies and testing and equipment and particularly those of dubious or unproved value. It also does not include spinal surgeries that are unlikely to be successful. If this results in less money for some medical providers, so be it.

If IMR provides quick answers that stick, I think we’ll see a marked reduction in the cases that go to IMR because, again, this is a huge cultural shift - a change in expectations.

Most doctors know pretty much what Blue Cross (or any other group health carrier) is going to approve and simply don’t recommend treatment that they know is going to be denied authorization - that wastes time, money and can create friction in the doctor/patient relationship. Whether Bill Gates would be able to pay for it himself is irrelevant.

IBR and IMR is meant to provide predictability and a means for bringing disputes to an end. IBR may end up with the doctor collecting too much or too little and IMR may result in outcomes that both sides think are unfair. However, society cannot afford to have people litigating every little area of disagreement, no matter how small, until the cows come home.

So whether the costs of IBR and IMR create a disincentive to challenge decisions or results on either side is irrelevant in the long run. The fact is that these represent the kind of cultural shift that, in the long run, may provide the predictability and stability that is necessary for a sound administrative system to operate.

IBR and IMR are intended to be long term investments in the system. We don't know what the return will be, but eventually we will. In any event, it’s now the law and we’ll just have to wait to find out.

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