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IMR Upheld 91.6% of UR Decisions in 2016

Friday, July 14, 2017 | 1332 | 0 | 0 min read

More than nine out of every 10 treatment denials were affirmed by the independent medical review process created by Senate Bill 863, the Department of Industrial Relations said in a report published Thursday.

The department said its review of 2016 data found that IMR upheld 91.6% of challenged UR decisions denying a requested medical service, and overturned 8.4% of UR denials. The UR uphold rate was 91% in 2014 and 89% in 2015.

The department reports that its IMR vendor, Maximus Federal Services, received fewer applications in 2016 than it did in 2015, but more of the applications were eligible for review.

Maximus received 249,436 IMR applications last year, compared to 253,779 in 2015. However, the number of eligible applications received in 2016 increased to 172,452 from 165,427 the previous year.

Failure to include the UR decision when applying for IMR was the most common mistake with applications. Of the 23,605 applications deemed ineligible in 2016, 9,744 were rejected because the injured worker or his attorney did not include the UR decision.

Another 2,129 IMR applications were rejected because they were not signed, and 404 applications were rejected because they were not signed and did not include the UR decision.

At the same time, the department said 5,346 IMR applications were rejected because the utilization review decision was invalid, and another 4,109 applications were ineligible because the IMR request was not timely.

Pharmaceuticals “Were by far the most common treatment category” disputed in 2016, the department said in its report, accounting for 43.5% of IMR decisions last year. Rehabilitation services accounted for 13.6% of IMR decisions, followed by diagnostic testing at 13.3% to round out the Top 3.

The department also said the average number of days from when an IMR case is assigned and when it is decided was almost cut in half from 24 days at the start of 2016 to 14 days at the end of the year. Maximus is issuing at least 13,000 IMR decisions every month.

The full report is here.

Comments

Tom Martin Jul 14, 2017 06:38 AM

The math in the article confirms the following tragic stats: in 2016, IMR confirms UR got it wrong 30,000 times, and the treating doctors (the vast majority of which are MPN members) got it wrong 225,000 times. That's just what went to IMR - we have no idea what was denied by UR and never appealed. Think of all the frictional costs to the system, TTD , delayed recovery, and lost work time that is being caused by poorly trained UR and MPN doctors EVERY SINGLE DAY and tell me the process isn't completely and utterly broken!

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Charles Cleveland Jul 14, 2017 07:59 AM

The current system is a well-designed mechanism not deliver medical care, shift the cost of injured worker benefits to taxpayers and maximize cost-containment profits. Every work day I have to have a conversation with an injured worker who is baffled by these denial statistics, they think that workers compensation is supposed to take care of their injury. Fewer doctors want to see workers compensation patients as the reimbursement rates are abysmal and the lien recovery process has become a nightmare. The MPN's are getting thinner overall, lack necessary subspecialties and most MPN doctors won't see injured workers without preauthorization. Even if you find an MPN doctor willing to see the applicant, there's a 91.6% chance that the injured worker will not get their necessary care. The system is rigged and broken.

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JAMES BADER Jul 14, 2017 09:54 AM

The entire purpose of the system of workers compensation has been defeated by the UR/IMR scheme of medical care denial. Its a daily struggle to explain to injured workers that although there injury has been accepted as work related, they are treating with an MPN physician who is a board certified orthopedic surgeon with 25 years experience, his requests for medical treatment are denied by a UR physician who never sees the patient, then that denial is affirmed by another physician more than 90% of the time. Hasn't this method of determining medical necessity defeated the entire purpose of the workers compensation system ?

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Christopher Lear Jul 14, 2017 11:26 AM

I wonder what the difference is in percentages between treating doctors getting UR denials who are MPN doctors as compared to those who are selected by the AA. Just curious.

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Kathleen Dixon Jul 15, 2017 05:26 PM

UR employs unlicensed RNs and doctors with specialties in Physical Medicine/Rehabilitation. These "doctors" were admitted to the Medical Board in the late 1950's & early 1960's. Many did not attend Medical School in the USA. Your "Life" is in the hands of a "C-" student, over 75 yrs of age! The AMA's criteria for UR doctors is a minimum "face-to-face" Skype exam. An IW Award for FMC is a worthless piece of paper--A "Contract" that has been "Breached" without reprimand.

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John Hill Jul 18, 2017 07:41 AM

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