Friday, January 10, 2014

DWC's IMR Meetings Premature

The noise over the volume of Independent Medical Review requests and Maximus' inability to cope with that volume is at top level and the California Workers' Compensation Institute's latest research paper is certainly going to add to the fury.

The Division of Workers' Compensation has scheduled round table meetings with interested groups for Monday and Tuesday. CWCI's release couldn't be more timely.

CWCI says that basically IMR (and underlying Utilization Review) are working as intended.

The say that only 5.9% of requested medical procedures are delayed, denied or modified through utilization review, and that three out of every four medical treatment requests are approved by claims adjusters without the need for additional oversight.

Moreover, CWCI found 76.6% of the 919,370 treatment requests it evaluated that were sent out for physician review were approved, 6.6% were modified and 16.9% were denied.

One-in-four treatment requests being sent for physician review and one-in-four of those physician-reviewed requests denying or modifying the recommendation means that 94.1% of treatments are approved and 5.9% are denied.

CWCI also reviewed 1,141 independent medical-review decisions that had been issued as of Jan. 2 and found 78.9% of denials are upheld by the administrative review and 21.1% are overturned.

Of the 919,370 medical treatment requests reviewed by CWCi researchers, "pharmacy" garnered fully 43% of all events - this is an astounding number and debunks quite a bit of what I previously thought was driving UR. Out of that amount 74% were approved, and 7.2% were modified, leaving 18.7% of the pharmacy requests denied.

What this really means is that out of all of the denied requests is that 395,329 "elevated" UR requests involved only pharmaceutical issues. Of that, 73,927 were denied, which means that about 18.5% of pharmaceutical requests end up denied.

CWCI recommends looking at a closed pharmacy formulary, like other states have implemented, to close that number even further.

What isn't answered is where all of these treatment request appeals to IMR are coming from.

As Jim Butler, president of the California Applicants' Attorneys Association, noted, CWCI looked at all treatment requests coming into the system including medical only claims, not just those from litigated cases or those involving severe injuries.

“Even if the percentage of denials appears small in relation to the number of requests approved, that still represents a large number of cases in which workers are not receiving the treatment recommended by their physician,” he said. “We estimate there could be 30,000 to 40,000 UR denials every month, and that needs to be addressed.”

I don't understand why that has to be addressed. UR denials do not equate to the same number of injured worker claims. A single injured worker may be making a dozen treatment requests from a couple of pills to diagnostic to surgical, all in a single treatment plan. To me this argument is obfuscating what really needs to be addressed - where the volume is coming from.

The study does not appear to answer why there are so many denials of treatment requests on cases that involve more severe injuries, Butler told WorkCompCentral.

But the study does sort of say what is going on, albeit indirectly - the more severe cases with attorney involvement likely are associated with elevated pain relief requests; i.e. narcotics and other associated opiate derivative drugs. That would explain why pharmacy requests are the bulk of IMR review events.

CWCI's paper is a good start, but only a start. IF interested persons are honest with themselves and each other at the table on Monday and Tuesday then there should be some very solid evidence concerning the cause of the unanticipated volume of IMR requests.

But I'm not counting on that. Everyone has their position to protect, and no one is going to be willing to take the heat and look like a bad guy nor give up a potential bargaining position when it comes time to modify regulations and/or lobby Sacramento.

The next step is to figure out WHO is making the IMR requests - whether there is any correlation to attorney involvement, whether there is any correlation to geographic zones (for instance earlier this week the Workers' Compensation Insurance Rating Bureau released numbers showing the Greater Los Angeles are bucking the trend on frequency by quite a large number) and whether such requests are part of some other strategy on either side of the bargaining table.

In my opinion the meetings scheduled by the DWC on IMR issues are premature. We know how much, but we don't know from whom or where. Answer those questions and some meaningful solutions can be crafted.

Without those answers everyone is just wasting time and resources. And frankly this may be one of those situations where in a couple of years everyone has adjusted and the volume declines because folks will know where the boundaries are.

CWCI's study can be viewed here.

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