IMR Removed Compromise

The Independent Medical Review process in California was developed to take medical decision making out of the workers' compensation courts so that the judges can spend more time deciding things that they presumably have more expertise on: evidence, disability rates, causation, etc.

And as in most things in workers' compensation, on the face of it the IMR process seemed reasonable. Certainly to me it seemed reasonable.

The Workers’ Compensation Insurance Rating Bureau in October 2012 projected the IMR process would save $390 million a year by keeping about 5,000 disputes from going before workers’ compensation judges each month.

At first the estimates seemed accurate. There were only 870 applications for IMR submitted in the first six months of 2013.

But then trouble transpired.

The number of requests increased to 4,410 in July when all dates of injury were eligible and then spiked to 15,731 in August. Since then Maximus has received more than 10,000 IMR requests each month.

Now there's a big blame game.

Employers and carriers blame the applicant attorneys for requesting IMR for everything.

Applicant attorneys blame employers and carriers for unreasonably denying everything.

Physicians seem caught in the middle and just throw up their hands in frustration.

The truth is probably that everyone is correct.

What the WCIRB failed to estimate is how many medical disputes never made it to workers' compensation judges in the first place because issues were negotiated, compromised and settled. The WCIRB measured cases before judges.

But work comp is no different than any other dispute resolution system; i.e. most cases never make it to a judge because the parties figure out how to settle.

The IMR process has completely eliminated any incentive to compromise and settle on disputed medical issues. The mandatory nature of the process has removed discretion from the claims management process on both sides of the fence.

We have seen this before in other areas of workers' compensation disputes - the attempt to reduce disputes by mandating a process takes away discretion thereby increasing burden on the alternative process beyond expectations.

In fact this is exactly what occurred when California mandated that every claims organization have a Utilization Review program in place. Nothing in the law said that every single request for a medical procedure must be reviewed, but for many operations it was much easier to simply mandate UR on every request.

Removing discretion is an organizational trick - and based on what is being measured could arguably result in better efficiency. Autonomous procedure has long been used to move goods and services through a system more economically.

The problem though is that a workers' compensation claim isn't a tangible item that can be mechanized.

We deal with human beings. Humans have emotions and engage in complex decision making processes that are influenced in part by those emotions.

Whether or not a requested procedure fits within the text book of medical treatment fails to take into account all of the other, numerous, complex factors that go into the decision making process and the human emotions that influence those decisions.

The reality is that the IMR process removed the ability to compromise.

THAT's why the volume of IMR requests has escalated well beyond estimates - because we didn't understand how many disputes never made it to court - we were only counting the ones that ended up there.

The likely truth is that many, many more medical disputes existed, but were settled before getting to a judge.

Maybe IMR isn't "broken." Maybe it's doing just what was intended. We just didn't measure the right thing to start with so our expectations were distorted.