Sandbagged

Monday, July 22, 2013 | 0

An excellent July 12 piece on independent medical review by Greg Jones of WorkCompCentral notes a troubling trend.

It seems that some IMR decisions are being rendered without the IMR physician reviewer having the medical records.

As of July 1, IMR is now in effect for medical disputes for all dates of injury, even injuries that occurred decades ago. If there is a timely utilization-review denial, the worker's remedy is to request an IMR review. Reviews will be done by doctors hired by Maximus, which has been contracted by California's Division of Workers' Compensation to perform the reviews.

Jones notes that in at least three cases, an IMR review was done where there were no records provided to the reviewer. Those decisions (which are posted online by the DWC) are IMR Decision 13-103 (involving a request for physical therapy), IMR Decision 13-114 (involving a request for strength and flexibility assessment) and IMR Decision 13-119 (involving a request for a CT scan of the head).

Final regulations on the IMR process have not been adopted. Currently the DWC is operating on emergency regs that were adopted in late 2012 (see link to those regs below).

The current version of the regs do require that the claims administrator send one year of treating physician reports and copies of documents that were submitted in support of the request for authorization.

Under the current regs, the parties have 20 days to submit medicals to Maximus.

But in at least three cases, it appears that Maximus decided to proceed with making a decision, despite the fact that the adjuster had not sent any documents.

An unrepresented worker would not have access to the documents, so if Maximus proceeds despite the adjuster's failure to comply with the regs, the worker has essentially been sandbagged.

If the worker is represented by an attorney, the attorney may not know what documents the adjuster has submitted. Also, in many instances, the applicant attorney has not been served with all of the medicals and has no way to get those medicals in short order.

The bottom line is that if Maximus is allowed to proceed without medicals, the worker's interests are prejudiced.

Labor union advocates who signed on to the Senate Bill 863 comp reform surely can not countenance the unfairness of this.

Maximus should announce how they are going to deal with this situation.

As Greg Jones' piece notes, "The emergency rules currently in effect authorize a fine of $250 for each day that a claims administrator fails to provide a copy of all reports of the employee's treating physician for the past year, up to a maximum of $5,000."

The DWC needs to issue an advisory noting that it takes this issue seriously and that it will proceed to enforce fines for this carrier behavior.

The current version of the IMR rules can be found here.