Report: Most California Workers’ Comp Medical Review Decisions Upheld

An examination of California workers’ compensation independent medical review decisions shows roughly nine-in-10 of disputed medical service requests reviewed by an IMR physician agree with the utilization review determination that the service is not medically necessary.

The IMR and UR process was established by the state’s sweeping workers’ comp reform law, Senate Bill 863, which was passed in 2012.

A report out in February from the California Workers’ Compensation Institute with updated figures may indicate the IMR process seems to be working as advertised, said Alex Swedlow, president of CWCI.

“It seems very steady, very stable,” Swedlow said. “It tells us that there is a consistent character in the decisions that are being made by the independent medical review.”

The report, which looks at 2015, also shows the volume of IMR requests has not tapered off, with close to 300,000 service requests undergoing IMR last year.

Half of those requests were for prescription drugs, according to the report.

The high volume is being driven by a “relatively small circle of physicians,” Swedlow said.

Roughly 85 percent of those physicians were identified in a study released last year that focused on 2014, according to him.

That report’s findings showed that out of the nearly 5,200 physicians associated with IMR disputes in the first three months of the year, the 10 percent with the highest volume of disputed requests were named in 70 percent of the IMR decision letters, while the top 1 percent accounted for 28 percent of the disputed requests that went through IMR.

“It’s basically the same physicians driving most of the volume,” Swedlow said.

Since January 2014, there has been a steady stream of IMR applications, and the volume increased by 19 percent from 2014 to 2015, according to the CWCI.

The study’s author compiled data from all 163,826 IMR final determination letters issued in 2015 by physician reviewers who conducted IMRs in response to denials or modifications of medical services requested for injured workers.

That data was used to examine changes like: the volume, timeliness and geographic distribution of IMRs; to determine the number, mix and uphold rates for medical services that were reviewed; to note the distribution and outcomes of pharmaceutical IMRs by drug type; the percentage of 2015 IMRs associated with the top 10 percent of medical providers with the highest volume of disputed medical service requests.

Requests for prescription drugs were by far the most common type of service sent through IMR, even though nearly 90 percent of the drug requests were still deemed medically unnecessary by the IMR physician, according to the report.

Requests for opioid painkillers remained the number one type of drug submitted for IMR, accounting for 27 percent of the IMR decisions rendered last year, although UR decisions to modify or deny opioid requests were upheld 88 percent of the time, according to the report.

Adding in other drug disputes, drugs accounted for nearly of 50 percent of all IMR letters, according to Swedlow.

However, there is a new law on the horizon that could help reduce some of the IMR volume being driven by medical disputes involving drugs.

Gov. Jerry Brown last year signed Assembly Bill 1124, which requires the Department of Workers’ Compensation administrative director to establish a drug formulary on or before July 1, 2017, as part of the medical treatment utilization schedule for medications prescribed in the workers’ comp system.

Among intentions of the new law is to establish evidence-based guidelines for access to appropriate medications pursuant to pain management prescription drug therapies.

“It’s the wish and the hope of the legislative intent in AB 1124 that our state-mandated formulary will help eliminate a large layer of these conflicts,” Swedlow said.