California Workers’ Comp Medical Dispute Resolution Letters Rose Last Year, Study Shows

April 22, 2019

After dipping for the first time ever in 2017, the number of workers’ comp medical dispute decision letters rose to an all-time high in 2018, according to a California Workers’ Compensation Institute study on the Independent Medical Review process used to resolve workers’ comp medical disputes.

The CWCI study also shows that in roughly nine out of 10 cases IMR physicians upheld the modified or denied medical service requests that they reviewed.

The CWCI study is based on a review of nearly 830,000 IMR decision letters issued from 2014 through 2018 in response to applications submitted to the state after a Utilization Review physician modified or denied a workers’ comp medical service request.

Researchers used data from the letters to: identify changes in the volume, timeliness, and regional distribution of IMRs; determine the number, mix, and uphold rates for the medical service requests that were reviewed; examine the distribution and outcomes of pharmaceutical IMRs by drug category; and measure the percentage of 2018 IMRs associated with high-volume medical providers.

Although state lawmakers expected IMR volume to diminish over time, the number of IMR determination letters has increased steadily since the process was introduced in 2014, with the only exception being a 2.6 percent decline in 2017, the study shows.

The latest figures show the number of IMR letters climbed to a record 184,733 in 2018, up 7.3 percent from 2017 and up 28.4 percent since 2014. The biggest increase in letter volume last year was in the Bay Area, which had 4,500 more letters in 2018 than in 2017, while San Diego had the biggest percentage increase (18.3 percent), according to CWCI.

The study shows that a small number of physicians continue to drive much of the IMR activity, with the top 1 percent of requesting physicians (122 doctors) accounting for 44.2 percent of the disputed service requests that underwent IMR in 2018, while the top 10 individual physicians accounted for 9.5 percent of the disputed requests.

The vast majority (95 percent) of the letters were in response to applications from injured worker representatives – almost all of them attorneys, the study shows.

The authors tallied 541 law firms that were named in more than 50 IMR determination letters in 2018, with the top 10 firms alone accounting for 15 percent of all IMR volume, the top 25 accounting for 25 percent and the top 50 accounting for 35.4 percent.

IMR outcomes were fairly stable as IMR physicians upheld the UR doctors’ modification or denial of services nearly 90 percent of the time, while the mix of services reviewed by IMR physicians in 2018 showed prescription drug requests continued to top the list, accounting for 46.3 percent of the IMRs, according to the study.

CWCI’s new study, “Independent Medical Review Decisions: January 2014 Through December 2018,” is posted under research tab on the institute’s homepage.


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