The Department of Industrial Relations(DIR) Division of Workers’ Compensation (DWC) has recently placed a search engine on its website with respect to IMR. This article will discuss IMR, the IMR Search Engine, and how this information can assist Injured Workers with respect to them obtaining medical treatment within the workers’ compensation system.
How Does an Injured Worker Get Involved with the Independent Medical Review Process?
In brief summation, Medical Providers within the California Workers’ Compensation System issue, as part of their treatment, “Requests for Authorization” or RFAs. These RFAs are subject to a Utilization Review (UR) process to determine whether the treatment should be authorized in accordance with workers’ compensation law. If the RFA is denied by the Insurance Company’s Utilization Review Process, the Injured Worker is entitled to appeal the decision through an Independent Medical Review (IMR) process. This IMR Process is run by the State of California and is contracted out to a Third-Party Vendor to administrate. Once there has been such an appeal, the Injured Worker is now within the IMR system. If there is an IMR appeal, the search engine can be used.
Per the DIR, “[t]he IMR program provides an expedient method to resolve medical necessity treatment disputes for all dates of work-related injury. The DWC has contracted with an independent medical review organization (IMRO) to conduct IMR on its behalf.”
What are IMR Decisions?
Per the DIR, “[e]ach IMR case pertains to one or more requested treatments that were denied, delayed or modified following utilization review (UR). The IMRO’s expert reviewers use evidence-based guidelines contained in the DWC Medical Treatment Utilization Schedule (MTUS) to determine whether to uphold or overturn the UR decision. The rationale for a reviewer’s decision for each requested treatment is provided in the IMR final determination letter.”
The IMR Decisions are sent to the parties involved in the cases.
What is the IMR Search Engine on the DWC Site? Why Is It Important?
The IMR Search Engine on the DWC Site is a tool which can allow the Injured Worker to look into the status of their IMR requests. They are able to view the published determinations that were made on their appeal. It can also be used to research prospective treatment and improve the likelihood of approval of their treatment requests. This research should be used in conjunction with their treating doctor. IMR decisions can provide some information and argument that should be placed in Requests for Authorization so that they get approved by Utilization Review. If denied, the additional information added into treatment requests can increase the likelihood over overturning an IMR decision.
How Should an injured Worker Use the Search Engine?
Before proceeding, it is helpful to understand the terminology relating to the searches.
What Are the Terms that are Used in the Search?
The following are the terms of interest provided for by the DIR with their descriptions. I have notated my thoughts with respect to some of these terms.
IMRO Case Number: The IMRO assigns a unique case number for each application. This is different than the “claim number” assigned to the workers’ compensation claim. The IMRO case number can be found on correspondence from Maximus Federal Services and on the Final Determination Letter. Do not use the injured worker’s claim number.
Note: If you have filed an IMR application, you will receive a letter from Maximus Federal Services. On that letter, there will be a case number
Date of Injury: This date refers to the date of injury of the claim for which the IMR is filed. Each IMR is directly related to one Workers’ Compensation claim.
Note: This is important. Many Injured Workers have multiple dates of injury. Therefore, it is important to play close attention to the date.
Date of Utilization Review Denial: The issuance date of the Utilization Review report that denied or modified the request from the treating physician. It is important to note that the” IMR application must be filed within 30 days of the date of the UR determination.” Also, “[a] copy of the UR report must accompany the signed IMR application at time of filing.”
Date IMR Application Received: This is the date that the IMRO received the IMR application. The database only includes applications for which a final decision was made.
Date IMR Letter Sent:
The date of issuance for the Final Determination Letter. This correspondence is sent to the injured worker, their representative(s), and their treating physician.
IMRO Reviewer Board Specialty
This is the Board Certification of the IMRO medical reviewer who reviewed and made the final decision on the IMR case. The IMRO medical reviewer does not necessarily have the same Board Certification as the requesting physician, but is knowledgeable and qualified to review the requested treatment.
IMR Case Outcome
This describes the overall outcome of the IMR review at the IMR case level. A case may contain one or more treatment requests.
- Uphold – None of the disputed items/services are medically necessary and appropriate.
- Overturn – All of the disputes items/services are medically necessary and appropriate.
- Partial Overturn – Some (but not all) of the disputes items/services are medically necessary and appropriate.
Note: This is very Important Overturns and Partial Overturns are important to Injured Workers. These are the “winners” for Injured Workers. These are the decision which can provide insight into how Injured Workers and their Medical Providers can better formulate their medical treatment requests so that they may be authorized.
Treatment Request Category
“Treatment request” refers to the medical treatment that was denied in UR and challenged through the IMR process. IMR cases have at least one treatment, or may have more than one. Treatment requests are classified into broad categories and subcategories; specific detail is found in the Final Determination Letter.
Note: This is a very good one to search. For example, you can search decision concerning the provision of transportation. You are able to review what decisions have been published and which ones overturned or partially overturned a utilization review decision.
What Is the Link to the IMR Search?
The link for it is as follows: https://www.dir.ca.gov/dwc/IMR/IMR-Decisions/IMR_Decisions.asp
What If I Need Legal Advice?
If you would like a “free” consultation concerning any workers’ compensation case, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. They have been helping people in Central and Southern California deal with their worker’s compensation cases for 28 years. for more information.