IMR Spike Likely Caused by Duplicate Applications, DWC Says

“I don’t buy it one bit....he has noticed in his office that the number of IMR denials has increased in the past two months, which would coincide with the notion that there has been an increasing number of applications. What’s happening...is that carriers are sending all treatment requests to utilization review, especially on older claims where treatment is being provided but there was no valid UR performed."   Alan Gurvey

The sharp spike in applications for independent medical review observed in the second quarter of this year is likely the result of duplicate and ineligible requests, according to the California Division of Workers’ Compensation.

IMR requests jumped 70% from 11,571 in March to 19,663 in April. That was the largest number of applications in a single month since the independent medical review process started at the beginning of 2013. The number of applications has not abated and despite a small decrease to 19,576 in May, a new high point was reached with 20,728 in June.

The total of 59,967 IMR applications submitted between April and June is 61% greater than the 37,083 applications from January through March, and is just 22% less than the 76,931 received in all of 2013.

But only 55% of the applications received in April, May and June were eligible for IMR, according to a presentation DWC Executive Medical Director Dr. Rupali Das delivered to the Commission on Health and Safety and Workers’ Compensation on Aug. 15. Approximately 20% of the requests were “duplicates” and an additional 25% were ineligible, according to a slide from the presentation titled “Recent Rise in Applications Likely Due to ‘Duplicates.’”

DWC spokesman Peter Melton said there is no evidence to suggest that the volume of duplicate or ineligible submissions is increasing. He said the agency doesn’t know why so many applications are defective.

“The high volume of ineligible applications may be due to the newness of the IMR process, Melton said in an email. “Once the parties to IMR become more familiar with the process, it is expected that the volume of ineligible applications will decrease.”

As for duplicates, Melton said it is possible that injured workers are resubmitting their applications if they don’t receive a timely response from their first submission. The division expects duplicate submissions will decrease once applications are being processed within 45 days of receipt, which will happen sometime around Nov. 1.

Alan Gurvey, managing partner of applicants’ firm Rowen, Gurvey & Win, said he does not believe that the increase in IMR applications has any relation to the number of duplicate or ineligible applications.

“I don’t buy it one bit,” he said in an email on Thursday.

Gurvey said he has noticed in his office that the number of IMR denials has increased in the past two months, which would coincide with the notion that there has been an increasing number of applications.

What’s happening, he said, is that carriers are sending all treatment requests to utilization review, especially on older claims where treatment is being provided but there was no valid UR performed.

“The defendant is doing everything to stop paying for treatment, so they will put requests through UR that have been authorized in the past or have not been UR’d timely,” he said. “The strategy is to terminate all treatment, regardless of whether it is justifiable or not.”

Gurvey also said he’s not convinced that the number of duplicate applications is as high as the DWC or Maximus have reported. A request could look the same on first glance, but it could contain new medical findings, evidence of a change in the workers’ condition or other information that is meant to further strengthen the case for why the treatment is necessary.

Some IMR denials he’s received note that the reviewer evaluated only one or two documents, he said.

“If the IMR reviewers who are receiving approximately $120 per review do not review all the relevant documents, I can be sure that the administration certainly is not doing so and cannot unequivocally determine what is a ‘duplicate’ request, and what isn’t,” he said.

Jim Butler, president of the California Applicants’ Attorneys Association, also said the problem stems from insurance companies increasingly using utilization review to deny treatment. As more medical requests are sent to UR and denied, more denials are being appealed to IMR.

An outdated Medical Treatment Utilization Schedule “compounds the problem,” he said, as does the “lack of any meaningful penalties for insurer misconduct, unjustifiable UR and IMR delay and denial of care.”

Butler also said it would be advisable to try to model the work comp utilization review on what is done in group health.

In group health, medical review “serves as a means of consumer protection to facilitate approval of necessary medical treatment,” he said. In work comp, “it is being abused by insurance carriers as a denial machine.”

Alex Swedlow, president of the California Workers’ Compensation Institute, said it’s inappropriate to compare group health to work comp. A group health policy states up front what is covered and what’s not, and private health insurance doesn’t pay for things such as experimental surgery and compound medications, he said.

“Group health has an advantage in that they say all this stuff is excluded up front,” he said. “In workers’ compensation, everything’s a discussion.”

Furthermore, in group health the fact that the patient most often has to cover some part of the costs through a copay, which Swedlow said serves as an additional check against unnecessary treatment.

The MTUS and utilization and independent medical review serve as the check in the comp system, he said.

A CWCI study published in January found only 5.9% of requested procedures are delayed, denied or modified through utilization review.

With DWC data showing that 84% of the 7,805 IMR determinations issued through Dec. 31, 2013, upheld the utilization review decision, Swedlow said he believes that “UR is getting it right.”

Published on 08/29/2014 by WorkCompCentral, authored by Greg Jones