Alex Swedlow, a certified rock star in the world of work comp analytics, held forth on medical dispute resolution as it exists in California.
MDR covers conflicts around the cost, utilization, and “standard of care”, these are evaluated against regulations, guidelines, fee schedules, and refereed by a judge, peer review doc, or some panel of designated experts.
California bill SB 863’s impacts were addressed, and include the following:
- 3 million liens processed over ten years, but the re-enactment of a fee to file liens in 2013 has cut lien filing fee by over 80%
- 90% of 2011-2012 liens came from a ten-mile radius in LA – but only 25% of WC claims
- change to reimbursement for ASCs dropped 28% after a 31% drop in the relevant fee schedule
Now on to the most fun part of 863 – the Independent Medical Review (IMR) “program”. As Alex said, “boy has IMR been proven popular.”
Volume is 12x the expected volume and runs above 12,000 per MONTH.
Just under 50% of all medical management fees are from UR.
Among the cases that go to elevated UR, about 43% are for pharmacy, most for opioids and compound drugs. A third of IMR decisions are also for pharmacy. There’s a lot of misunderstanding about how many medical requests are handled internally vs done by an outside physician reviewer.
Just under 6 percent of all treatment requests were denied or modified before getting to IMR. 4.7% of all treatment requests are denied at the IMR stage.
Less than one in 20 treatment requests are ultimately denied via IMR.
75% approved internally, 18% are approved by elevated review; 4.7% are ultimately denied by the IMR process.
Less than one in 20 treatment requests are ultimately denied via IMR.
CWCI’s next step is to look into how a pharmacy formulary would affect pharmacy spend and scripts; looks like it would dramatically reduce the use of opioids, brand drugs, and compounds.
Stay tuned and check their website for updates on CWCI research.
