To date, 94 percent of medical treatment requests are approved after initial/internal UR and elevated physician-based UR.
At most, 4.7 percent of all medical treatment requests are denied.
Those are the headlines from CWCI’s just released analysis of all completed IMR decisions (see 1/8/14 report), an exhaustive and precise project that involved a manual review of each of those requests and resolution thereof.
CWCI’s summary indicates “IMR agrees with approximately 79 percent of the elevated physician-based UR decisions.”
What does this mean?
There are two main takeaways. First, there’s no widespread denial of care to injured workers, far from it. The research clearly demonstrates that while the vast majority of treatment requests are approved, the vast majority of the IMR decisions uphold the UR determination to deny or modify treatment. (Update)
Which leads to takeaway two. Do not assume this means the IMR process - or UR itself is unnecessary or superfluous. While a cursory review of the results would lead an uniformed reader to draw that conclusion, the report provides insight into the potential downside of ending UR. The authors reviewed a study conducted by the Washington state work comp fund, known as L&I. Back in 2000, L&I stopped requiring UR for MRIs, as almost all were approved. A few years later, they looked at the volume of MRIs conducted had jumped dramatically.
Here’s what they concluded:
L&I reviewed the effect that the elimination of UR had on MRI use and found a 54 percent increase in spinal MRI scans and a 72 percent increase in lower extremity MRI scans following the elimination of utilization review, and the reviewers were unable to identify any variable other than the removal of the UR requirement that accounted for the increase in MRI utilization. [emphasis added]
Other research into California-specific utilization further emphasizes the risk of ending UR, you can find it in the report at the link above.
That said, there’s no question the volume of IMR requests is much higher than anticipated; word is the State is considering various ways to address the volume including adding other vendors. But focusing on results to date, it is also clear the process is working as intended – as an exception management process.
As stakeholders gain more experience with UR and IMR, I’d expect the volume of requests to decrease.
What does this mean for you?
We know now that the IMR process is not a “medical treatment denial scheme” perpetrated by carriers looking to deny care.
Far from it.