Independent Medical Review FAQ
What is Independent Medical Review ("IMR")?
Independent Medical Review ("IMR") is a process available to injured workers who are dissatisfied with utilization review decisions in workers' compensation cases. IMR was created as part of a comprehensive bill-Senate Bill 863, or SB 863-aimed at reforming worker's compensation law in California.
For what dates of injuries will IMR be available?
As of January 1, 2013 for injuries occurring on or after that date, and as of July 1, 2013 for all dates of injury, IMR will be used to decide disputes regarding medical treatment in workers' compensation cases.
Why was IMR created?
Under the current system, it typically takes nine to 12 months to resolve a dispute over the treatment needed for an injury. The process requires: (1) negotiating over selection of an agreed medical evaluator, (2) obtaining a panel, or list, of state-certified medical evaluators if agreement cannot be reached, (3) negotiating over the selection of the state-certified medical evaluator, (4) making an appointment, (5) awaiting the examination, (6) awaiting the evaluator's report, and then if the parties still disagree, (7) awaiting a hearing with a workers' compensation judge and (8) awaiting the judge's decision on the recommended treatment. In many cases, the treating physician may also rebut or request clarification from the medical evaluator, and the medical evaluator may be required to follow up with supplemental reports or answer questions in a deposition.
SB 863 replaces those eight steps with an IMR process similar to group health that takes approximately 40 (or fewer) days to arrive at a determination so that the appropriate treatment can be obtained.
Who can request an IMR?
An IMR can be requested only by an injured worker following a denial, modification, or delay of a treatment request through the utilization review (UR) process. Employers and insurance carriers cannot request review of treatment authorizations.
An injured worker can be assisted by an attorney or by his or her treating physician in the IMR process.
IMR will not be available where there is a dispute over anything other than the medical necessity of a particular treatment requested by the injured worker's physician (such as cases where the injury itself is in dispute).
If a health care provider is dissatisfied with the amount of payment received for services rendered to an injured worker, that provider may be eligible for an Independent Bill Review (IBR). For more on IBR, please visit this site: http://ibr.dir.ca.gov/index.shtml.
Who pays the cost for IMR?
The cost for IMR is paid by the claims administrator.
Why might a case be considered "not eligible" for IMR?
Not all cases will be eligible for IMR. Examples of reasons why a case might not be eligible include:
- The IMR request was not filed within 30 days from the date the final utilization review decision was served
- The IMR request is a duplicate
How does an injured worker request IMR?
When a utilization review agent sends out their decision, they are now required to include an application for IMR. Injured workers seeking an IMR should complete this application and send it to the address listed on the form within 30 calendar days from receipt of the utilization review decision. The completed application is the means by which an IMR is initiated. For more information, see http://imr.dir.ca.gov/request_imr.shtml.
If you are an injured worker and you received a utilization review that did not include the application for IMR, please contact the Division of Workers' Compensation: http://www.dir.ca.gov/dwc/ContactDWC.htm.
Who conducts the IMR?
Under SB 863, the Division of Workers' Compensation (DWC) can contract with one or more Independent Medical Review Organizations (IMROs) to conduct IMRs. The DWC has used their authority under SB 863 to contract with MAXIMUS Federal to perform IMRs as an IMRO.
MAXIMUS Federal, in turn, utilizes an extensive panel of medical specialists to conduct the actual medical review. MAXIMUS Federal employs a rigorous selection process, ensuring that only the most highly qualified candidates conduct medical reviews. For each medical review, MAXIMUS Federal takes steps to match the disputed issues to a specialist possessing skills and expertise in the disputed issues. These medical specialists are employed by MAXIMUS Federal, not your employer or the State of California. They are also cleared for any potential conflicts before being assigned to review a case. All this is done to ensure that reviews are truly independent of outside influence or bias.
How long does the IMR process take?
Generally, an IMR takes 30 calendar days to complete. If the case involves an imminent and serious threat to the health of the injured worker, the IMR will be completed in no more than three calendar days.
How do parties get information on a pending IMR?
To get the status on a pending IMR, the parties to an IMR and their representatives can contact 1-855-865-8873 toll-free between 8:00 a.m. and 5:00 p.m. PST, Monday through Friday. Parties may also email IMRHelp@maximus.com at any time. A response will be provided within two business days.
What if an injured worker is not satisfied with the IMR decision?
There is a right to appeal an IMR determination, to the trial level Workers' Compensation Appeals Board ("WCAB"), on the basis of fraud, conflict of interest, or mistake of fact. The reviewer's underlying medical decision-making, however, cannot be overturned by a judge. The remedy, if an appeal is granted, is referral to a different reviewer for another review.