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Mar
19

California’s IMR program – clarity at last.

Much clarity was brought to the IMR process, costs, efficiency, and IMR filers by the next speaker, CWCI SVP and CFO Rena David.  Speaking about 2014 data, Rena noted:

  • 4.1 percent of treatment requests were “IMR eligible”
  • There were about 261,000 IMR service decisions made in 2014
  • Days from application to final determination was 134 in January 2014l that dripped to 50 in December
  • 91% of the IMR reviews upheld the UR decision, and thereby the denial was deemed as appropriate.
  • Overall, 5.4% of all treatment requests are being denied or modified

Pharmacy accounted for almost 45% of requests, with decisions upheld 92% of the time.  And;

  • 12% of IMRs were for compounds, consistent with overall figures; 98% of the time compound requests were deemed to be not medically necessary.
  • 23% of IMRs for anti-depressants overturned the UR decision, the highest percentage for any drug category.
  • Only 2 percent of anti-anxiety medication denials were overturned
  • Oftentimes, information available AFTER the original UR decision was made was used in the IMR process to overturn the UR decision.

There were ten individual providers who represented fully 15% of claims; the top two individual providers each submitted the equivalent of 10 requests a day…

A key takeaway – Rena noted that for judges and other non-medical people to be in a position to determine what medical treatments are and are not appropriate is “unfathomable”.

She also noted that “without oversight, injured workers may receive deleterious care”, citing:

  • A worker anxious abut an an epidural injection was denied propophyl
  • A complete spinal fusion was requested for a 76 year old man with evidence of arthritis.

What does this mean for you?

IMR works, and would be working a lot better if bad actors weren’t jamming the system with spurious requests for damaging, or at best inappropriate, medical services.


4 thoughts on “California’s IMR program – clarity at last.”

  1. IMR works for who? All of your data comes from insurance company funded studies, or from groups funded by carriers.

    Many carriers are referring cases to UR companies that they own. What is the cost of the UR and IMR?

    Wheel chair bound claimants are being denied modifications to their homes so carriers can increase profits. Waiting 170 days for medical decisions is working? Is this journalism or propaganda? IMR companies are failing to match medical records to cases and claiming it is the adjusters fault.

    The cost of name brand drugs are going through the roof and your company is helping big pharma reach the highest profits of any industry.

    1. Jeffrey
      Thanks for the questions. To the extent you are willing to have a conversation about this I’m happy to do so.

      Couple points.

      1. The 170 day figure was 15 months ago; 50 is from 12/2014.

      2. Note 45% of IMR requests are for drugs; much of that is for opioids and other drugs without clinical support. One was for propophol; hardly appropriate for injection management. Another was for the spine surgery noted in the post. These are not helpful for the patient.

      While the UR company is as you note contracted by the payer, the IMR is independent as it is state contracted.

      As to purported failure of some entity to match records, you may not have read the latest report indicating a significant percentage if those ‘non-matched’ records were because the request or claim was closed for various reasons. Workcompcentral reported on this earlier this week.

      Finally facts are facts. These data came from dwc. The analytics are based on the data. And CWCI did the analytics. If you don’t believe the result Id ask why.

    1. Jeffrey
      Thanks for the note. A subsequent article indicated a majority of the cases allegedly missing records had already been closed. My sense is we don’t know precisely how many records were late or who might have been responsible.
      I’d suggest that waiting for that data would be helpful.

Comments are closed.

Joe Paduda is the principal of Health Strategy Associates

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