The number of independent medical reviews used to resolve California workers’ compensation medical disputes fell sharply in the first half of 2020 as the pandemic took a toll on the state’s economy with statewide unemployment spiking to a record level and workers comp claim volume on the decline.
That’s according to the latest tally by the California Workers Compensation Institute.
Under California law every workers’ comp claims administrator must have a utilization review program to assure that the care provided to injured workers is supported by clinical evidence outlined in medical guidelines adopted by the state.
Most treatment requests are approved by UR, but in 2012 state lawmakers adopted IMR to give injured workers a chance to get an independent medical opinion on treatment requests that UR physicians deny or modify.
IMR took effect for all claims in 2013, and CWCI began monitoring IMR activity in 2014. In its latest review, the institute tallied 70,273 IMR decision letters issued in the first half of 2020 in response to applications submitted to the state compared with 85,318 letters issued in the first six months of 2019 – that’s down 17.6%.
Once again, about 40% of the letters included decisions on multiple services, but with the decline in letter volume, the total number of primary service decisions fell by 19.3% from 148,069 in the first half of 2019 to 119,514 in the first half of 2020, according to CWCI.
While IMR volume was down, a review of IMR outcomes in the first half of this year saw little change.
“After reviewing the medical records and other information provided to support a disputed treatment request, IMR doctors upheld the UR physician’s modification or denial of the service in 88.8% of the IMRs in the first half of this year compared to the 88.2% uphold rate from 2019,” the CWCI stated.
As has been the case since IMR was first adopted, prescription drug requests accounted for the largest share of the January through June IMR decisions (39.8%), though that percentage was down from nearly half of all IMR disputes prior to the state’s adoption of the opioid and chronic pain treatment guidelines at the end of 2017 and the Medical Treatment Utilization Schedule Prescription Drug Formulary in January 2018, according to CWCI.
Even with the guidelines and the formulary, opioids still accounted for 29.2% of the 2020 prescription drug IMRs – down only slightly from 30.9% in 2019. Requests for physical therapy; injections; durable medical equipment, prosthetics, orthotics and supplies; diagnostic imaging; and surgery together comprised 40% of the IMRs from the first half of 2020, while all other medical service categories combined accounted for 20.2 percent of the disputed requests, according to CWCI.
A small number of physicians continued to account for most of the disputed medical services that went through IMR this year. The top 10% of physicians identified in the IMR decision letters issued in the 12 months ending in June 2020 accounted for 83% of the disputed service requests during that period, while the top 1% accounted for 40% of the disputed service requests, the CWCI tally shows.
Additional data and analyses on the IMR data through June 2020 has been published in a bulletin, which CWCI members and subscribers will find under the Communications tab on the CWCI website.
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