A quick, non-judicial way to resolve disputes regarding medical treatment provided to injured employees, an independent medical review or IMR is a request the injured worker can make to the claims administrator. This appeal is made when a request by a treating physician for a particular course of medical treatment is denied or modified by a claims administrator for the reason that the treatment is not medically necessary. Independent medical reviewers decide whether the treatment provided to the injured worker was medically necessary or unnecessary on the basis of a comprehensive medical records review. To ease the review process and obtain an accurate review, many of them utilize reliable medical review services.
A request for medical treatment must go through a utilization review (UR) process (requested by employers and insurers) to determine that it is medically necessary. If the UR denies, delays, or modifies a treating physician’s request for medical treatment on the grounds that it is medically unnecessary, the injured worker can place a request for a review of that decision via IMR. The costs of IMR are paid by employers and insurers, and are based on the nature of the medical treatment dispute and the number of medical professionals needed to resolve the dispute. While IMRs do help reduce unnecessary medical treatments for injured workers, there is a concern now that it could increase costs because these reviews are being requested more often than expected.
IMRs have mostly endorsed utilization review findings, and according to the February 2016 report of the California Workers’ Compensation Institute, almost 89% of the IMRs in 2015 upheld UR decisions. While IMRs help deny inappropriate care and save costs in that direction, the frequency of these reviews is preventing the workers’ compensation system from achieving its full cost savings potential. For instance the California Workers’ Compensation Insurance Rating Bureau in Oakland said in February that there were 163,826 independent medical review determinations in 2015, an increase of nearly 19% from 2014. Insurers and employers were expected to pay an amount of 60 million dollars for IMRs in the year 2015, with the fees expected to increase loss adjustment expenses by 2.4%. The frictional costs did not drop with the IMR process, which as a result did not bring in the expected savings.
However, some experts feel that IMRs are good because they prevent doctors from using non-evidence-based practices to treat injured workers. The Workers’ Compensation Insurance Rating Bureau in California highlighted in November that IMRs and other provisions of California’s comp reforms brought in $770 million in annual savings for the state’s workers’ compensation system so far. Ultimately, the independent medical review process may bring about considerable reduction in some workers’ compensation costs. It may also bring down the number of adverse medical events, extended disability and thereby reduction in costs to employers, insurers and taxpayers.