In California, workers’ compensation claims must go through a process to determine whether the proposed medical treatment for an injured worker is backed by clinical evidence. This process is called utilization review (UR), and it’s used to decide whether or not to approve prescription drugs, tests, surgeries, and procedures recommended by the worker’s treating physician.
If a reviewing physician denies or modifies a proposed treatment, the injured worker has a right to disagree with the decision and request a second opinion. This is known as an independent medical review (IMR). After being adopted by state lawmakers in 2012 and steadily increasing since 2013, California is now seeing the volume of independent medical reviews level off.
Since its inception, there has been a heated debate over whether the independent medical review process has improved the resolution of medical disputes and advanced the quality of care for injured workers. While the volume of requests for independent medical reviews has exceeded original projections, data from 2016 shows that 91 percent of IMR decisions are in agreement with the utilization review opinion. This means only 9 percent of denied or modified medical requests submitted for independent medical review were overturned in favor of the worker.
How does the independent medical review (IMR) process work?
All injured workers have a right to request an independent medical review of their proposed treatment plans. To request IMR, an employee or his or her workers’ compensation attorney must submit an application for independent medical review as well as a copy of the utilization review denial of treatment. The deadline to file an application for IMR is within 30 days from the date of the utilization review decision.
Once eligibility for IMR is determined, Maximus (the independent medical review organization) designates a medical reviewer to conduct the investigation. A determination on whether to uphold or overturn the UR physician’s denial or modification is made within 30 days of receipt of a worker’s IMR application and supporting documents. In most cases, the IMR physician agrees with the decision made during utilization review. However, if the disputed treatment is deemed medically necessary, the claims administrator must implement the decision immediately.
Can I appeal an IMR determination?
If you are dissatisfied with the determination made during independent medical review, you can file an appeal with the Workers’ Compensation Appeals Board (WCAB). You must file an appeal within 30 days from the date the decision was mailed. A workers’ compensation attorney can help you fill out the proper forms and submit them on time to maximize the chances of the WCAB reversing the final determination in your favor.
Have you been injured on the job and disagree with your proposed medical treatment?
If you’ve been hurt at work and require medical care for your injuries, it’s easy to feel like your voice isn’t being heard. At the Law Office of Gerald Brody & Associates, our workers’ compensation attorneys will fight hard to defend your right to high-quality medical treatment and protect you from unnecessary tests and procedures that could negatively impact your recovery.
Call us today at (619) 528-9800 to schedule your free case evaluation.