IMC Guidelines and Reimbursement

Saturday, July 6, 2002 | 0

Starting in 1997, the California Industrial Medical Council began developing and publishing guidelines for the treatment of common work injuries, and evaluation protocols for the writing medical-legal reports. These guidelines can be found at the IMC web site, http://www.dir.ca.gov/IMC/physicians.html.

One of the biggest complaints we hear from physicians about the workers' compensation system is that it seems impossible to get reimbursed for treatment and/or reporting. Reading and following the IMC guidelines can go a long ways towards alleviating some of the delays. While not law, these guidelines are closely followed not only by insurance claims departments, but also by the WCAB when billing becomes disputed. The IMC tates:

Treatment guidelines are designed to assist providers by providing an analytical framework for the evaluation and treatment of the more common problems of injured workers. The guidelines are intended to assure appropriate and necessary care for injured workers diagnosed in these types of industrial conditions. Due to the many factors which must be considered when providing quality care, health providers shall not be expected to always provide care within the stated guidelines. Treatment authorization, or payment for reatment, shall not be denied based solely on a health care provider's failure to adhere to the IMC guideline. The guidelines are not intended to be the basis for the imposition of civil liability or professional sanctions. They are not intended to either replace a treating provider's clinical judgment or to establish a protocol for all injured workers with a particular condition. It is understood that some injured workers will not fit the clinical conditions contemplated by a guideline.

However, the IMC also acknowledges the import of following as closely as possible the guidelines:

A provider may vary from these guidelines, if in his or her judgment, variance is warranted to meet the health care needs of the injured worker and that variance remains within the standards of practice generally accepted by the health care community, and the provider documents the need for the variance in the evaluation report or the medical treatment record in the manner that is generally accepted by the health care community.

The key to reimbursement is thusly stated by the IMC in italics - documentation in the manner generally accepted by the health care community.

Past articles that have appeared on this site for the physicians segment have stressed the importance of a coherent, well written medical report. These elements become even more important when you want to render treatment that is outside the scope of the IMC guidelines.

Some general rules apply: First, read the guidelines. It sounds logical and basic, but starting out with the basics is your best path to ensuring success in the rendition of treatment that may be outside the scope of the guidelines.

Second, a trial course of treatment protocol within the guidelines is in order. How do you know that the treatment prescribed by the protocol won