Following the 2014 Winter Convention A Year of Independent Medical Review & the Medicine Behind the Review session, 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. Click here to find many free resources to help you navigate the IMR system, including a series of practice tips and a podcast.
Click on the topic below to jump to the question.
Alternative Treatment Options
Other studies of the UR & IMR Process
Notice of Assignment for Treating Physician
Medical Provider Education
Limit UR to More Costly Medical Treatment
Knox-Keene Act and IMR Decisions
Home Health Care
Window to Send Additional Information
UR Process & Change in Material Facts
Distinguishing Diagnostic Testing
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
- So, a UR determination denies a medical treatment request citing a Guideline in support of that determination. IMR may uphold the determination. Yet, there are seldom any recommendations for alternative treatment. Many are concerned that the denials do not lead to alternative treatment options. Is there some consideration to encourage UR and/or IMR to provide alternative treatment that the MTUS supports? Wouldn’t this serve to expedite appropriate medical treatment?
Answer: In setting the rules concerning IMR, DWC was worried about exceeding its statutory authority. The statute does not allow for such a requirement. It would clearly be helpful, but to mandate it would require a statutory change. (Suggestion: The IMR Committee of CAAA would suggest that if recommendations were made by IMR, and the treating doctor then prescribed the treatment that it should be required that it be authorized without the need for further UR/IMR.)
- When we look at costs and problems in the WC system, we are always looking at indemnity claims – more serious claims. Medical-only claims are usually quickly resolved and don’t cost the system a lot of money. Is there any data gathered, or that will be gathered, about the use of UR in medical-only cases vs. indemnity cases vs. indemnity cases with severe disabilities; i.e. in the life pension range? Same, regarding the use of IMR? Cases with future medical awards in place vs. new not-yet-finalized cases? What other studies are lined up to study the UR & IMR process at this time?
Answer: Right now, DWC agrees it would be helpful to have more data and more analysis. The problem is that they are only getting IMR data, not UR data. In order to get UR data, it would require a partnership with a number of UR companies or claims administrators that would have to provide the necessary data. Every claims administrator has its own data. The Administration is interested in seeing the true impact of IMR. Maybe there are other studies out there that involve this question? Maybe CHSWC will consider looking at this issue?
- Per Labor Code Section 4610.5, the physician is allowed to advocate on behalf of the patient for the medical treatment recommended. Should it be mandated that the treating physicians get sent copy of the Notice of Assignment when it issues?
Answer: In the final Regulations, pending approval, in Section 9792.10.4(b) it mandates this, as the section says “(b) Within one business day following a receipt of the Administrative Director’s finding that the disputed medical treatment is eligible for independent medical review, the independent review organization delegated the responsibility by the Administrative Director to conduct independent medical review pursuant to Labor Code section 139.5 shall notify the parties claims administrator, employee, if the employee is represented the employee’s attorney, and the requesting physician in writing that the dispute has been assigned to that organization for review.” [Emphasis added.]
- Is there any consideration to have Maximus and its reviewers reach out to provide education to the medical community about its experiences reviewing recommendations in industrial injury cases? Medical provider education is an important key to a smooth-running and efficient UR process. What steps are being taken to assist the community in such education?
Answer: DWC considers Maximus a contractor. They are, in fact, a contractor with the State to provide IMR services. Maximus will educate the community regarding processes. However, it is up to the DWC or other private entities to educate on the other issues pertaining to IMR. DWC is getting feedback and will provide tips to the community when they speak at events throughout the State. (CAAA continues to be a leader in educating the community on IMR issues. Check back periodically on this website for more information on UR and IMR issues.)
- Physicians have expressed concern about being able to verify the proper mailing address and/or fax number to submit medical treatment requests. Right now, there is no uniform manner in which carriers communicate this information to the physician community. Why can’t this be regulated?
Answer: Mr. Parisotto expressed that he has heard this concern from the claims administrator side, that they are not getting timely treatment requests because the RFAs are not getting to the right place. The DWC wants to hear from all parties if this is an ongoing issue. Note, in the final regulations claims can “designate” a location or fax for this purpose, see 9792.6.1(t)(3) which states “(t) "Request for authorization" means a written request for a specific course of proposed medical treatment. (3) The form request for authorization must be signed by the treating physician and may be mailed, faxed or e-mailed to, if designated, the address, fax number, or e-mail address designated by the claims administrator for this purpose. By agreement of the parties, the treating physician may submit the request for authorization with an electronic signature.” [Emphasis added.]
- From start to finish, the UR to IMR determination process easily costs the insurer $1,000 to $1,200 per dispute. This cost is less than that for many of the treatment recommendations. There are a number of other states where UR is limited to more costly or more controversial medical treatment costs. Is there any such consideration for California?
Answer: Dr. Das recognized that evaluating treatment requests is a delicate balance. Generally, medicine has moved in the direction more toward evidence based medicine vs. cost based approaches. States that have tried cost-based approaches have had mixed results. In California, it could require a statutory fix or we could discuss what “UR” should include and consider regulations to address this issue.
- The statute (LC 4610.5) that sets up the hierarchy of review is not used in the Knox-Keene Act that is applicable to group health IMR decisions; do you think that is a concern that drives the high rate of denials?
Answer: It is really unclear at this early stage of the implementation of IMR whether the more limited hierarchy is a factor in the high rate of denials. Dr. Das points out that in group health in California there is a formal internal review that has to occur before it even gets to IMR and that is where a lot of issues get resolved.
- Home Health Care (HHC) services is not covered by the MTUS. Is it not a reviewable issue by UR/IMR? A CAAA member reports receiving a denial from Maximus for HHC and the sole basis was that HHC was not covered by the MTUS.
Answer: Presence of a treatment or condition not in the MTUS is not a reason to not consider the request. The MTUS is finite and very limited in its scope. The fact that something is not in it is not a reason for it not to be eligible for IMR. DWC wants to see these types of determinations for quality assurance and to discuss with Maximus. CAAA encourages such examples to be forwarded to the CAAA IMR Committee so that they can be formally submitted to DWC for consideration.
- Recently some IMR determinations included this conclusion “"After careful review of the medical records and documentation provided, the employee's diagnosis is considered a non-industrial injury."
Answer: DWC Staff has not seen this yet. DWC wants to see these types of determinations for quality assurance and to discuss with Maximus, and encourages such examples be forwarded to the CAAA IMR Committee so that they can be formally submitted to DWC for consideration.
- Is there any further consideration to require that the insurer send medicals to IMR and give the physician, injured worker or the injured worker’s agent some short window to send additional information? The concern is when the 15 days runs concurrently efforts are duplicated and information that may be relevant to a correct determination may be missed.
Answer: Experience will give us information, and if needed this will be adjusted. DWC’s concern at the onset was to make sure that any relevant documents get to Maximus so this is why they went in that direction with the Regulation.
- Since the statute allows a treating physician to resubmit a treatment request within 12 months of the IMR denial if there has been a change in material facts, it is required that that new request go through the UR process if not authorized by insurance, right?
- Diagnostic testing to evaluate impairment is distinguishable from diagnostic tests that are considered and recommended for medical treatment, right? For example, for lumbar spine impairment a consideration is testing done by way of both MRI and EMG/NCV testing.
- What is the remedy if the adjuster does not send the relevant records and applicant has not been provided the reports? Example: IMR denied carpal tunnel surgery where the carrier did not send a positive EMG/NCV report that should have been considered and issued in the prior 6 months.
Answer: If Maximus did not get the necessary information, then a request will have to be resubmitted with this “new” information for consideration and go back up the UR/IMR ladder.
What steps is the medical unit taking to insure that the medical reviewer actually reviews the medical records submitted? Does the DWC have the resources for this kind of oversight?
Answer: DWC is concerned about the quality coming out from the medical reviewers. They monitor it as best they can. DWC gives feedback to Maximus when warranted on the broad scope and end result, but DWC cannot monitor individual reviewers. A big challenge is that the IMR determination is not like a medical-legal report. It has to be written in lay language, and that is the goal.
May I submit a statement or video from the applicant for IMR’s consideration?
Answer: Nothing in the statute or regulations precludes doing so. However, it is unclear what weight is given to such a submission.
What percentage of IMR forms have been filled out incorrectly by carriers and what is done by DWC/IMR when that is the case?
Answer: The DWC does not have this data and they are not tracking this data. They are trying to push the IMR Applications if they can through the process even in the case of technically deficient IMR Applications. However, the DWC cannot process an IMR Application unless the UR determination is submitted with the Application. The audience at the Convention was reminded of this very important requirement.
Is there a conflict here between the MTUS and the statute which includes the right to have medical treatment that does not just “cure” but also serves to “relieve” the injured worker of the effects of their injury?
Answer: DWC assured us that Maximus was educated on the law on this issue.
- For Mr. Parisotto or Attorney Dombchik “Are treating physicians allowed to bill for the time they or their staff have to devote to (1) preparation of the new more complicated RFA forms: (2) peer to peer reviews with the UR doctors and (3) appeals of UR non-certs to the IMR process?
Answer: Mr. Parisotto reminded us that the RFA itself is not a reimbursable form. Maybe they will build it in going forward. As to the other issues “They can bill, not sure if they will get it back.”
- Dr. Das, clarification on your chart regarding ‘Top Ten Reviewer Specialties’ as it did not list any orthopedic doctors? What specialty(ies) are considered in the ‘Surgery’ category?”
Answer: Dr. Das confirmed that orthopedic surgeons were lumped into the all surgeons category and surgeons are the third most utilized category of reviewer.