A new analysis of 2015 independent medical review (IMR) outcomes shows there was no significant reduction in IMR volume in the first quarter of this year, even though the independent medical reviewers continue to concur with the utilization review (UR) physician’s denial or modification of treatment in about 90 percent of the cases.
The CWCI analysis compares data from 33,909 IMR determination letters issued in the first three months of this year in response to applications submitted to the state after a utilization review (UR) physician modified or denied a requested medical service to similar data from the 137,781 IMR decisions issued in 2014. State legislators who enacted IMR expected the volume of requests would decline following an initial learning curve as doctors, attorneys and others involved in the process became familiar with the types of treatment that would meet the evidence-based medicine standards and be approved through UR and IMR, but the new data indicate that after more than 2 years, IMR volume has yet to subside. A review of the IMR decisions issued in the first quarter shows that after reviewing the patient’s records and any additional information provided in support of the request, the IMR physicians upheld the UR doctor’s modification or denial of the service 89 percent of the time, nearly matching the 91 percent uphold rate from 2014. The mix of services submitted for IMR also showed little change, as prescription drugs again topped the list, accounting for 48 percent of the first quarter IMR decisions (vs. 45 percent in 2014), with the UR denial or modification upheld in 92 percent of those cases. Requests for prescription drugs, physical therapy, durable medical equipment, injections and diagnostic tests and measurements together accounted for ¾ of all services submitted for IMR in the first quarter, though requests for surgery, which accounted for 4.4 percent of the IMR cases (vs. 4.7 percent in 2014) surpassed diagnostic tests and measurements as the fifth most common type of service submitted for IMR, even though the uphold rate for modifications or denials of surgical requests held steady at 89 percent.
The first quarter IMR results also show that a relatively small number of physicians continue to account for the majority of the disputed medical services, as the top 10 percent of physicians named in IMR decision letters (516 providers) accounted for 70 percent of the IMR requests, though that was down from 83 percent last year, while the top 1 percent of physicians (52 providers) accounted for 28 percent of the disputed service requests in the first quarter, down from 44 percent last year. In addition, the study documents continued geographic variation, with 38 percent of the first quarter IMR decision letters addressed to Los Angeles County recipients – 1.5 times the proportion of claims that come from that region, whereas in all other regions of the state the percentage of IMR decisions was either in line with or disproportionately low relative to the percentage of claims from the region.
CWCI has published more details on the first quarter IMR outcomes in a Spotlight Report, “California Workers’ Compensation Independent Medical Review: 1stQuarter 2015 Outcomes,” which CWCI members and subscribers can access in the research section of the Institute’s website, http://www.cwci.org/.