Is Maximus Paying $100 for Independent Medical Reviews?

Friday, February 8, 2013 | 0

California's Independent Medical Review system is starting.

Workers with injuries after 1/1/13 will in most cases have to fight treatment denials by asking for Independent Medical Review. After 7/1/13, IMR will apply to pre-1/1/13 injuries.

Insurers or self-insured employers will pay the cost of IMR, which will be substantial.

Recently adopted DWC emergency regulation 9792.10.8(a)(1)(A)(i) specifies that the cost of a basic IMR to be done by Maximus, the IMR provider contracted with the Department of Industrial Relations, will be $560.

So it was of great interest when the issue of IMR came up in a panel at this weekend's winter CAAA convention in San Diego.

Past CAAA President Brad Chalk posed a question to Christine Baker, Director of the Department of Industrial Relations. Chalk noted that he had heard that some doctors had received notice that Maximus was hiring doctors to do IMR reviews.

Chalk noted that he had heard that doctors doing IMR reviews were going to be paid something in the range of $100. "Is that correct?" Chalk asked Baker.

Baker responded that she was not sure what Maximus pays the doctors doing reviews.

Baker essentially indicated that this was not a DIR/DWC concern since it is a contractual matter between Maximus and the doctor agreeing to do the reviews.

A moment later Baker came back to the point, noting that she will "look into it."

If Chalk's information is right, then we have a curious situation. Could Maximus be charging $560 for IMRs and paying doctors $100? If so (which is currently unconfirmed), this is quite an eye opener.

First, it would indicate a huge administrative "mark-up" by Maximus. Should employers be paying for that?

Second, how can California's DIR expect quality medical reviews if doctors are to be paid so little to do the reviews? If payments are that low it would seem extremely unlikely that a physician would bother to read contextual medical records to get an understanding of the worker's medical situation, what has been tried, what prior treatments did and didn't work and whether the requested treatment meets one of the hierarchy of standards specified under the Labor Code.

IMR will have little credibility if the doctors doing the reviews give short shrift to the process because they are paid so little.

After all, IMR reviews will not be appealable except for the most narrow grounds.

Ms. Baker needs to get on this issue immediately. The workers' comp community has a vital interest in understanding the cost structure behind the IMR system.

Julius Young is an applicants' attorney with the Boxer & Gerson law firm in Oakland. This column was reprinted with his permission from his Workers' Comp Zone blog.