LISTEN UP, IMR IS HERE! WHAT ARE YOU DOING ABOUT IT?

 

As of July 1, 2013, every dispute over a utilization review (UR) decision regarding medical treatment for a work injury must now be resolved by Independent Medical Review – IMR. But, as with any new program, many of us have more questions than answers. What do we do when we get a UR decision? How long do we have to act? What if the UR decision is late? Can we submit more evidence with an IMR appeal? What happens if the IMR review finds the treatment was necessary? Or, does it agree with the UR determination?

 

WHAT IS CAAA DOING ABOUT IT?

To answer these and many other questions, CAAA has now issued several Practice Tips on the new UR/IMR process. To supplement these tips and provide even more background to the IMR process, CAAA is providing a free 35-minute podcast to California’s workers’ compensation community. The podcast is a condensed form of a presentation given at the June 2013 CAAA Convention in Las Vegas. You can access this free IMR podcast.  We hope that the Practice Tips and this podcast will provide a basic understanding of the UR and IMR processes as defined under SB 863.

“CAAA is dedicated to ensuring injured workers get SB 863’s promised prompt access to necessary medical care,” said CAAA President Larry Stern. “We are closely following implementation of the new IMR process to resolve medical disputes, and want all interested parties to have access to our expertise to improve how IMR is working. “  We hope these practice tips will improve understanding and operation of IMR towards its objective of fair, prompt resolution of medical treatment disputes.

  • Following the 2014 Winter Convention: A Year of Independent Medical Review & the Medicine Behind the Review, the moderator, Adam Dombchik, had a follow up meeting with Division of Workers’ Compensation (DWC) Acting Chief Counsel George Parisotto and DWC Medical Unit Director Dr. Rupali Das to review some of the unanswered questions:  CAAA is posting those answers here.
    • Other studies of the UR & IMR Process
    • Notice of Assignment for Treating Physician
    • Medical Provider Education
    • Carrier Communication
    • Limit UR to More Costly Medical Treatment
    • Knox-Keene Act and IMR Decisions
    • Home Health Care
    • Non-Industrial Injury
    • Window to Send Additional Information
    • UR Process & Change in Material Facts
    • Distinguishing Diagnostic Testing
    • Missing Records
    • Ensure Review of Records
    • Video Statement for IMR
    • Incorrect IMR Form Statistics
    • Conflict between MTUS & Right to Medical Treatment
    • Physicians Billing for Time
    • Top Ten Reviewer Specialties
  • Free IMR Podcast
  • "IMR Intensive" Seminar in LA & Berkeley on September 21st
  • Surviving SB 863Surviving SB 863: A Treating and Evaluating Doctor's Guide to Getting Medical Treatment Approved. Program recorded March 15, 2014
     
  • Practice Tips on UR and IMR
    • #08 SB 863 Practice Tip - Utilization Review-Validity Issues - with addendum
      Practice Tip  republished on 10/23/2013. Subsequent to issuance of this tip, Judge Colleen Casey issued a decision on case out of the San Francisco District Office of the WCAB detailing her findings that an invalid UR denial was within her jurisdiction, and subsequently found substantial medical evidence existed to Award the recommended medical care.  The case did not go through the IMR process.  Judge Casey cites the cases in this tip in support of her decision.  This is an excellent read and illustrates the application of the current state of law on a relevant fact pattern.
       
    • #09 SB 863 Practice Tip - Utilization Review Utilization Review Post SB863 This is the second in a series of four Practice Tips dealing with Utilization Review (UR) and Independent Medical Review (IMR) as set forth in SB 863. Although mandatory UR has been in place since 2004, there were a number of changes made in SB 863 that could help facilitate this process and reduce disputes over UR determinations. This Tip describes the most important changes and reviews some key issues in the new UR process post-SB863.
       
    • #10 SB 863 Practice Tip - Independent Medical Review Post SB863 - As of July 1, 2013, every dispute over a utilization review (UR) decision regarding medical 
      treatment for a work injury must now be resolved pursuant to the new Independent Medical Review (IMR) process as set out in Labor Code §§ 4610.5 and 4610.6. This Practice Tip reviews the statutory and regulatory rules applicable to the new IMR process. Included with the Tip is a two page flow chart to assist you in understanding and navigating IMR. Regulations governing IMR can be found in California Code of Regulations, Article 5.5.1, Utilization Review Standards,
      commencing with §9792.6.
       
    • #11 SB 863 Practice Tip - IMR Determinations - This is the last in a series of four Practice Tips on UR and IMR. This Tip looks at the IMR determinations posted on the DWC website. As of  August 1, 2013 the DWC had posted more than 350 individual medical treatment requests on its  website. A summary of those determinations is linked to this Tip and is available on the CAAA  website [click here]. This is the only place where you will find this comprehensive summary of IMR  determinations in one file:
       
    • #12 SB 863 Practice Tip - IMR Checklist - CAAA’s IMR committee recently issued a series of Practice Tips reviewing the Utilization Review and Independent Medical Review processes as adopted in SB 863. This Tip summarizes advice from those tips and provides a “checklist” that you can follow in reviewing your options and preparing an application for IMR.

    • #14 SB 863 Practice Tip - Getting to "Yes" with UR and IMR - Considerable attention has been drawn to the fact that more than 30,000 IMR applications were filed over the last two months, but that is actually only a symptom of the real problem – which is that there were at least that many denials of medical treatment requests, and probably thousands more where the applicant didn’t know to file for IMR or just gave up. By any measure, having more than 15,000 treatment requests denied by UR each month represents a profound failure for California’s workers’ compensation system. Thus, the real challenge facing the system is not how to reduce the number of IMR appeals, but how to reduce the number of UR denials. There are several possible solutions,
       

    • #15 SB 863 Practice Tip: IMR Final Regulations – Top Ten Tips - While much of the focus has been on the UR and IMR process recently, this Tip will provide an overview of the Medical Treatment Utilization Schedule (MTUS) treatment guidelines themselves, and provide an orientation to their use in the California Workers' Compensation System.

    • #16 SB 863 Practice Tip - Utilization Review and the MTUS - While much of the focus has been on the UR and IMR process recently, this Tip will provide an overview of the Medical Treatment Utilization Schedule (MTUS) treatment guidelines themselves, and provide an orientation to their use in the California Workers' Compensation System.
       
    • #17 SB 863 Practice Tip - Enforcing the RIght to Medical Treatment "Cure or Relieve" - This tip will discuss the applicability of the "cure or relieve" standard to UR and IMR determinatoins.  Utlization Review and Independent Medical Review (IMR) processes.
       
    • #18 SB 863 Practice Tip - Post Dubon II: Appealing the AD's IMR Determination - This tip will discuss appealing the AD’s IMR determination post Dubon II


Surviving SB 863: A Treating and Evaluating Doctor's Guide to Getting Medical Treatment Approved. Program recorded March 15, 2014
Cover PageIf you missed CAAA's comprehensive seminar, "Surviving SB 863" Seminar on March 15, 2014. A recording of the programs are available on our bookstore
 

"IMR Intensive" Seminar in LA or Berkeley on September 21st

If you missed CAAA's comprehensive seminar, "IMR Intensive" Seminar on September 21, 2013. A recording of the programs are available on our bookstore.

The seminar is taught by medical and legal experts who will describe this new paradigm, and teach you what has to be done to get your client’s medical treatment authorized.