IMR Talk

Healing?

It's been easy to criticize Independent Medical Review in California, due to evidence of records mismanagement, unanticipated volume, and late determinations.

But statistics reviewed last week at the California Workers' Compensation Institute's annual meeting implicate a very small percent of overall IMR requests poisoning the well.

For instance, according to Rena David, chief operating officer and chief financial officer for CWCI, almost half of the 138,000 IMR decision letters issued in 2014 were the result of treatment requests from only 134 providers.

134 physicians in the top 1% accounted for approximately 60,720 IMR decisions, while the 1,323 providers in the top 10% accounted for about 114,540 final decisions.

10 individual providers accounted for 11% of the decisions issued last year covering 15% of the disputed medical services and 14% of the claims with treatment issues that were eligible for IMR.

More than 91% of the approximately 15,180 decisions attributed to these 10 providers had determinations that the requested treatment was not necessary.

25% of IMR decisions are sent directly to the injured worker, 5% are sent to the care provider as the patient representative for the process.

Two-thirds of the decisions were sent to the injured worker's attorney.

72 attorneys, representing the top 1% of litigators measured by volume of IMR decisions, were associated with 18% of all decisions issued in 2014, David said. The top 10% of attorneys – 718 in all – accounted for 65% of the final decision letters.

And of course most of this action comes from the greater Los Angeles area, which has been identified in the past by CWCI as an anomaly in claims statistics.

Approximately 24% of workers' compensation claims in California originate in Los Angeles, but the area accounts for 36% of IMR decisions, David said. The Bay Area produces about 19% of claims and accounts for 19% of IMR decisions, while the Inland Empire and Orange County generate 18% of claims and account for 16% of IMR decisions. Counties in Northern California and in the Sierras account for about 5% of industry claims, combined, but only 3% of independent medical-review decisions.

In 91% of service request reviews, IMR upheld the UR decision, according to David, which means IMR agreed with the original UR decision that the service was not medically necessary. It also means that 8.6% of UR decisions were reversed, which means IMR felt it was medically necessary.

When put into context, that's a rather large percentage - nearly 10% of the time UR gets it wrong according to these stats, so it seems that if you aren't happy with the UR decision then it's worth the while to seek an IMR review.

About 75% of all medical treatment requests in California are approved by the claims administrator without further review, according to CWCI. Of the other 25% elevated to physician level UR, 94% of requests were approved and 6% were denied.

It is just these 6% of cases that are eligible for IMR. And even with 91% of these treatment disputes being denied through IMR, David said the vast majority of treatment requests are ultimately approved.

"Rather than a wholesale denial of care, we're estimating anywhere between 94% and 95% of treatment requests are approved," she said.

Pharmaceuticals (principally opioids and related drugs) accounted for 44.7% of services, and the UR decision was upheld on those denial of drugs 91.9% of the time. At the low end was evaluation and management services, which accounted for 1.7% of the decisions and were upheld 79.5% of the time.

So is there a problem with UR and IMR? If you're talking about timeliness and efficiency of records management (even according to anecdotes from claims administrators themselves), yes, Maximus and DWC need to do a better job.

If you're talking about gross numbers and the vast majority of service requests (typically not litigated cases, and likely medical only cases or cases with very little disputed disability claims) then the process works just fine, though there may be some issue with timeliness and efficiency.

We also know for certain that a small percentage of cases account for a large, disproportionate, share of costs to the system. It's those cases where most of the "noise" comes from.

Much of the other presentations at the CWCI meeting dealt with paying for value - perhaps paying a little more for quality medical care in return for better outcomes (which means lower disability terms).

When I compare the stats on UR and IMR as presented by CWCI, I'm not sure paying more to that small percent of providers who create most of the dispute would change things. Something tells me that those providers aren't really in the game of healing...