In recent articles, we’ve shared the details of State Compensation Insurance Fund (SCIF)’s denial of continued care for an injured worker on false grounds, and how the only recourse open to the injured worker, Independent Medical Review (IMR), is stacked in favor of the insurer.
Today, we dig further into the systemic flaws of the IMR system and probe exactly why injured workers have no realistic path to success — even when the insurer’s reasons for denying the treating physician’s requested treatment are demonstrably untrue or irrelevant.
As you read, SCIF has denied a treating doctor’s request for critical rehabilitative therapy for head trauma for one worker injured while repairing California highways. California cannot act fast enough to fix this flawed, unfair system.
The DWC maintains an Independent Medical Review (IMR) web page, which explains that medical treatment disputes will be resolved through IMR rather than the courts:
IMR, as devised by California regulators, is an ‘appeal’ system arguably set up to grant insurers like SCIF every advantage, a system that leaves injured workers fending for themselves as they attempt to navigate confounding and rigid IMR requirements. California essentially shunts treatment authorization battles from open court to IMR, where the playing field is arguably far less even.
As the DWC’s own statistics show, this “efficient process” is practically nirvana for payers. Below is a table from a 2022 DWC study of IMR results in the last quarter of 2021 by region, demonstrating that insurers win at IMR over 91% of the time.
That’s right: Maximus, the entity to which the DWC outsources IMR, takes the side of UROs in 91.3% of authorization disputes.
In other words, doctors treating patients face-to-face are contradicted by people looking only at paperwork. When the injured worker attempts to appeal, other people look at paperwork and almost always decide the first people looking at paperwork had it right.
Presumably, the California legislature intended to create a relatively simple process for an injured worker to dispute a UR decision by filing for IMR. Per California Labor Code Section 4610.5, requesting IMR should require only a signature and a stamp:
Yet the process is much more complex, especially for an injured worker unaccustomed to the language of workers’ comp bureaucracy. Remember: the injured worker must file for IMR within 30 days of the UR decision denying treatment; physicians cannot file for IMR to dispute an incorrect UR denial.
To file for IMR, the injured worker must take the following mandatory steps:
This can be even more daunting than it appears at first glance.
First, UROs can issue UR decisions that are dozens of pages long, all of which the injured worker must copy, attach to the UR form, and snail-mail (or fax, if the injured worker has access to either a fax machine or a time machine headed to the mid-’90s) to the DWC. On top of that, the completed IMR form must be copied and sent to the claims administrator.
If the injured worker makes the slightest mistake, the dispute is deemed ineligible for IMR.
Second, given the consequences of failing to timely file for IMR, the injured worker must have proof of mailing or a fax receipt proving the successful, timely delivery of the IMR form and UR decision to the DWC.
For example, the DWC will automatically rule the dispute IBR-ineligible if the injured worker fails to send a copy of the UR decision with the IMR form, or fails to make it to the post office within 30 days of receiving the UR decision. Once deemed ineligible for IMR, the denial stands for 365 days.
In the case of the injured worker denied therapy by SCIF/EK Health, even if:
…there would still be only a 9% chance of success by DWC statistics.
Since the medical report was somehow lost between SCIF and EK Health after SCIF (verifiably) received it with the RFA, what rational adult is willing to bet that SCIF will make sure Maximus gets the report for IMR purposes?
So we’re absolutely clear, the SCIF sends Maximus the medical records and documents. This is how IMR works in a case like this:
It’s a classic failure of circular logic. It would be funny if it weren’t for the tragic consequences for the injured worker.
Perhaps that’s why we get comments like the one below from doctors. We cannot independently verify anything alleged in this comment, but if this is the experience reported by doctors, it’s time to consider reform.
DaisyBill provides content as an insightful service to its readers and clients. It does not offer legal advice and cannot guarantee the accuracy or suitability of its content for a particular purpose.