In 2012 Senate Bill 863 (SB 863) was signed into law. What started out as a one page bill regarding the appointment of an Administrative Director of the Department of Workers Compensation (DWC) morphed into a 158 page bill with sweeping changes to the California Workers Compensation system. The purpose behind the bill was to stop abuses including overtreatment, doctor shopping, and excessive billing by medical providers among other things.
One of the main features of SB 863 was the creation and implementation of Independent Medical Review (IMR). Essentially IMR is a process put into place to resolve disputes regarding medical treatment. This is done by having an independent doctor review an injured worker’s medical records to determine the reasonableness and necessity of medical treatment requested by a treating doctor. This is a records review process only; there is no actual examination of an injured worker.
As stated in the State of California, Department of Industrial Relations website:
“California's workers' compensation system uses a process called independent medical review (IMR) to resolve disputes about the medical treatment of injured employees. As of July 1, 2013, medical treatment disputes for all dates of injury will be resolved by physicians through an efficient process known as IMR, rather than through the often cumbersome and costly court system.”
While SB 863 mandated the creation of IMR, the rules and regulations regarding the IMR process were put in place by the Administrative Director of the WCAB. The IMR itself is conducted by Maximus Federal Services, Inc., a private corporation contracted by the State of California DWC.
IMR is designed to be an expeditious way to resolve disputes regarding the necessity for medical treatment. Before the implementation of IMR disputes regarding the need for medical treatment were resolved by a Workers Compensation Appeals Board (WCAB) judge who had the authority to order medical treatment. As a result of IMR this authority, with very limited exceptions, has been taken away from the judges. These exceptions are limited to instances of an untimely Utilization Review by an insurance company claims examiner.
The IMR process is initiated by an adverse Utilization Review (UR) determination. UR is a process internal to an insurance company or third part administrator that reviews, approves, modifies, delays, or denies in whole, or in part requests to provide medical treatment made by an injured worker’s treating doctor. UR is initiated by a “Request For Authorization” (RA), which is a formal written request by a treating doctor to provide medical treatment. Any appeal of an adverse UR determination must be accomplished through IMR.
IMR is not available in situations where liability for a claimed injury is in dispute or a claim is denied. Additionally no IMR is available in situations involving missing or incomplete medical records preventing completion of UR, or the issue in dispute is not related to medical treatment, for example a dispute regarding Temporary Disability payments. In situations where a claim is initially denied but then found to be compensable by a WCAB judge, UR and IMR will likely be used to assess any requested medical treatment.
Generally, an IMR decision cannot be appealed except under very limited circumstances[1]. These include situations where the IMR was:
1. Conducted in excess of the Administrative Directors scope of powers.
2. A determination was procured by fraud.
3. The Medical reviewer was subject to material conflict of interest,
4. The IMR determination was the result of bias based on race, national origin, ethnic group, religion, age, sex, color, disability, sexual orientation.
5. A mistake of fact not subject to medical opinion.
As the above illustrates the avenues of appeal are very limited in nature and available only under certain circumstances. A disagreement with the result of an IMR based simply on a conflict with a treating doctor’s recommendation is not a sufficient basis for an appeal. It is important to remember that IMR is designed to achieve finality of medical disputes regarding treatment.
In 2018, treatment denial were upheld at a rate of 90%. DIR Annual Report on IMR
In situations where requested treatment has been denied by IMR injured workers options for medical treatment are limited. This would include self-treatment at their own expense or treatment with a doctor willing to accept payment on a lien basis with the hope that the treatment provided will ultimately be found to be compensable at a later date.
Unfortunately injured workers are put in a position of having to self treat for injuries that occurred at work. In some cases insurance companies are refusing to buy out future medical treatment as part of a settlement. This refusal is based on the availability of health insurance under the affordable care act. Essentially the insurance companies are “dumping” injured workers into a government backed health insurance system, thereby avoiding having to pay for medical treatment that is properly the responsibility of the Workers Compensation Insurance company.
[1] Cal. Labor Code Section 4610.6(h)
