When a payor’s utilization review organization (URO) denies treatment recommended by an injured worker’s treating physician, the only recourse is for the injured worker to appeal the denial to Independent Medical Review (IMR) administered by Maximus Federal Services.

A recent analysis of Maximus’ IMR decisions by California Workers’ Compensation Institute (CWCI) found that Maximus upheld the overwhelming majority of payors’ utilization review decisions.

The notion of IMR as a largely futile pursuit works to the advantage of the CWCI, an insurers’ and employers’ group with the stated aim of analyzing data “to improve benefit delivery.”

As we explained in an earlier post, with the exception of emergency treatment, providers are not allowed to submit IMR appeals to Maximus; only injured workers’ can submit IMRs to Maximus.

Even though the provider requests the treatment, only the injured worker or their attorney can request IMR if the injured worker believes the recommended treatment was incorrectly modified or denied by the payor’s URO. According to California Code of Regulations (CCR) § 9792.10.1, the provider may only “join with or otherwise assist the employee” by submitting relevant documents and responding to independent reviewer questions.

The CWCI study analyzed 648,540 IMR decisions reviewers rendered from 2014 to 2017. The major takeaways were twofold:

1. IMR Rarely Overturns UR Decisions

In 2017 IMR reviewers upheld the payors’ UR decisions 91.2% of the time; this uphold rate is consistent with previous years. Requests for pharmaceuticals dominated the list of requested treatment in IMR cases, amounting to almost half (46%) of all disputed treatments. Of those pharmaceutical requests, 29% were for opioids.

Considered alongside California’s new drug formulary, the high number of “uphold” decisions on pharmaceuticals sends a clear message: the state is steering workers’ comp towards more conservative drug policies.

The CWCI study also points out that most IMR requests came from workers treated by a relatively small group of physicians. 85% of the IMR disputes originated with requests from the top 10% of physicians named in those disputes. The not-so-subtly implied narrative: a few pesky providers are requesting medically unnecessary treatment (mostly drugs), but IMR reviewers are holding the line.

2. IMR requests decreased for the first time in 2017

From 2016 to 2017 IMR requests decreased a modest 2.2%. For employers, insurers, and their respective claims administrators, any statistically significant decrease can be trumpeted as progress.

If fewer workers are requesting IMR, it may be a sign that workers and their attorneys have less confidence in their chances of obtaining treatment that providers request. With automatic authorization and stricter new standards for UR processes in effect, news of this decrease in IMR requests may serve to counter any perception of a more provider-friendly authorization system.

The report’s overall message is clear: the odds of overturning a given UR decision are low, and fewer workers and attorneys are willing to try.

That conclusion has more direct implications for workers and their attorneys than for providers. However, it’s hard not to see this insurer-sponsored analysis as a warning to providers to err on the conservative side when requesting treatment.

The CWCI report is available for purchase at a price of $24.00 on the CWCI web store. The report is free for members (insurers and employers).

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