What is Independent Medical Review – an overview in the CA work comp system
As of July 1, 2013, if you do not agree with a denial, delay, or modification of a medical treatment request that has gone through Utilization Review (UR), an appeal must be made through the Independent Medical Review (IMR) process. IMR applies to all workers’ compensation claims regardless of your date of injury and/or regardless of prior Stipulations with Request for Award giving you lifetime medical care. IMR also applies even if an Agreed Medical Examiner has indicated that the treatment is appropriate.
What is IMR? Independent Medical Review (IMR) is a non-judicial way to resolve disputes about the medical treatment of injured employees. If a request by a treating physician for a specific course of medical treatment is delayed, denied or modified by a claims administrator for the reason that the treatment is not medically necessary, the injured employee can ask for a review of that decision by physician conducted IMR. The State of California (through the Administrative Director) has contracted with Maximus as the independent medical review organization. Maximus then contracts with medical professionals to perform the IMR. The medical professionals remain confidential and their names are only disclosed to Maximus. We have no way of finding out the name of the medical professional making the IMR decision.
What is a medical necessity treatment dispute? A medical necessity treatment dispute is a request by a treating physician for a specific course of medical treatment that has been modified, delayed or denied by Utilization Review (UR).
Does IMR apply to any and all treatment denials? Yes. It includes all medical treatment that the workers’ compensation carrier is responsible for, including but not limited to, denials for medication, physical therapy, injections, chiropractic, psychotherapy, cane, walker, orthotics, transportation, x-rays, MRI, CT scan, surgery, etc.
If your treatment is denied, delayed or modified by your claims examiner, employer, workers’ compensation company, or Utilization Review Company, you will received the IMR form and an envelope to file for the IMR process. It is important that you notify your attorney’s office of the denial immediately as there is strict time periods in which to file the appeal. Attorney’s offices do not always receive a copy of the denial from the carrier or your doctor and therefore need you to inform us of any denials.
IMR must be requested by properly filing the appeal within 30 days of the date of service of the UR decision. If the appeal is not filed within the 30 days you may lose your right to file the appeal for at least one year. To request IMR an application for IMR must be mailed within the 30 days along with the UR denial to:
DWC – IMR
c/o Maximus Federal Services, Inc.
P.O. Box 138009
Sacramento, CA 95813
The IMR decision is binding for one year. If IMR finds that you are not entitled to the treatment your doctor cannot ask for the same treatment again for one year, unless there is a new injury/issue.
Each IMR request is paid for by the workers’ compensation carrier and the cost presently ranges from $475.00 to $740.00 depending on the degree the reviewer holds, how many degrees the reviewer has, as well as whether the review is made on an expedited basis for “emergency” treatment. In order to request an expedited IMR the treating physician’s certification that the employee faces an imminent and serious threat to his or health must be included.
IMR request can only be made by the injured employee or their attorney, the physician who made the request, or the provider of emergency medical treatment. If the injured worker is unrepresented they may designate a parent, guardian, conservator, or relative or other person to act as an agent on their behalf.
After the AD receives the IMR review request, the AD will then determine if the request has been appropriately made and forward the request to IMR. IMR then has 30 days from receipt of the IMR form and supporting documentation in which to make their determination. Unfortunately, there are no time limits for the AD to review requests and forward them to IMR.
The IMR determination can only be appealed in very few circumstances involving proving fraud, material conflict of interest, bias on the basis of race, national origin, ethnic group identification, religion, age, sex, sexual orientation, color or disability, or the determination was the result of plainly erroneous mistake of fact. This will be almost impossible to accomplish. Even if one is successful in overturning an IMR determination the dispute is then returned to the AD for reassignment to a different medical reviewer.