The number of independent medical examinations used to resolve medical disputes for California workers hit an all-time high in the first half of 2021, as statewide unemployment remained stubbornly high, non-COVID workers’ compensation claims remained lower at pre-pandemic levels, millions of Californians continued to work from home, and efforts to reduce prescription drug conflict appear to be paying off, according to a new analysis from the California Workers’ Compensation Institute.
California law requires every worker claims administrator to have a usage review program to ensure that care provided to injured workers meets state-adopted evidence-based treatment guidelines.
Most treatment claims are approved by the UR, but in 2012 state lawmakers embarked on a sweeping workers’ compensation reform and passed the AMT to allow injured workers to get medical advice independent on requests that UR physicians deny or modify.
The IMR came into effect for all claims in July 2013 and the CWCI began monitoring IMR activity in 2014. The latest CWCI review found that 68,044 IMR decision letters have issued during the first half of 2021 in response to requests submitted to the State, down 3.3% from 70,368 letters issued in the first half of 2020, while the latest annual tally shows that 136,738 letters have issued in 2020, down 16.6% from 163,899 letters in 2019 and down 26% from the record 184,735 letters in 2018.
A review of the IMR results revealed that after reviewing medical records and other information provided to support a contested treatment request, IMR doctors confirmed the doctor’s change or denial of service. of UR in 91.2% of MRIs in the first half of 2021, this was up slightly from the maintenance rate of 88.4% in 2019, according to the CWCI.
Disputes over prescription drug claims continued to represent the largest share of IMR decisions from January to June (35.5%), but this percentage declined from almost half of all IMR disputes before the ‘State adoption of opioid and chronic pain treatment guidelines in late 2017 and implementation of the Medical Treatment Utilization Schedule Prescription Drug Formulary in January 2018, according to CWCI.
Opioids still accounted for 25.8% of prescription drug MRIs in 2020 – more than any other class of drugs – although this percentage is down from 32.2% in 2018. As demands for pharmaceuticals have increased represented a declining share of IMR, since 2018, requests for physiotherapy; injections; and durable medical equipment, prosthetics, orthotics and supplies accounted for an increased share and together accounted for 35% of all MRIs in the first half of 2021, while all other medical service categories combined accounted for 29.5%, according to the CWCI report.
The CWCI has published additional data and analysis on IMR data through June 2021 in a newsletter that institute members and subscribers can access on the CWCI website.
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