Approve or Deny Medical Care
Workers Compensation Independent Medical Review Process – After a work related injury, the injured person should be permitted to see a doctor at an industrial clinic within the workers’ compensation insurance network. The physician within the network is known as an MPN doctor. That MPN doctor will request needed treatment to cure or relieve the effects of the industrial related health condition. The requests for medical care will either be approved or denied by the insurance company as part of a utilization review process, also known as UR for short. UR blocks a significant amount of requests by MPN doctors even though these doctors are within the insurance carrier's network. In essence, UR is a second lawyer of control exercised by the carrier to make sure appropriate procedures and treatments are being requested, as well as to keep costs down. There is a way to appeal adverse or denied medical care under the new Independent Medical Review process.
Workers Compensation Independent Medical Review Process (IMR)
Appeal Utilization Review with IMR
Independent Medical Review, or IMR for short, is the new appeals process whereby decisions denied in the UR process are either overturned, modified or upheld. In other words, it is the new and only avenue by which an injured worker can make the workers' comp. carrier pay for treatment denied by UR. IMR is the appeals process that is used by applicants whose requests for medical treatment and services have been rejected by the utilization review. The IMR is an organization of physicians that works independently and outside the network of UR. When the UR denies, modifies or delays an injured worker’s request for medical care, he/she can move to get the IMR doctors to review the request. The resulting decision becomes the final decision that is made in regards to any type of medical care requested. I.e. there is no higher appeals procedure beyond this point. This is true even if the injured worker hires a workers' compensation attorney. Under the new Labor Code provisions, the judge does not have jurisdiction to override a UR denial unless the UR decision is late.
Utilization Review Concept Summary
Although utilization review (UR) is usually done by insurance companies, an employer may authorize medical treatment without consulting UR physicians if he/she believes the treatment is reasonable. (stated by the supreme court). As long as the UR standards are intact, a non-physician can review and potentially approve the treatment request sent by the network physician of the injured. This often happens when an adjuster approves a request for authorization by a doctor treating the injured worker. *A request can be approved quickly and without any additional medical review if it is straight forward and does not lack any substantial information and consequently is not controversial.
Physician Review: By and on the large, physicians employed by the insurance company to review requests made by network doctors either approve or deny requested treatments. An approved request can be made by an employer, but the decision to deny can only be made by a physician. An employer or their insurer who hopes to deny a request must therefore seek medical opinion in all circumstances.
Procedures For Approving, Denying and Delaying Care
Procedure for approval of treatment
- Defendant is required to give notice in writing if the request for treatment has been approved by UR
- The decision of approval must be communicated not only to the requesting physician, but also to the injured and his/her attorney
- Communication must be within 24 hours of the decision by phone, fax or email. If the communication was through the phone, it must follow with a written notice to be sent within 24 hours of the initial communication.
- If the treatment requested was approved by UR, the employer MUST provide the care.
Procedure for modifying, delaying or denying treatment
- A request is MODIFIED if the physician reviewing the request finds that some of the treatment or services requested are not medically necessary. Hence, in that case, the physician moves to modify the treatment requested accordingly.
- A request is DELAYED if additional evidence was needed. In such case, the reviewing physician requests the lacking information to come to a final decision regarding the initial request.
- A request is DENIED if the requested treatment is not authorized.
- All these decisions must be communicated to the requesting doctor, the injured and his/her attorney within 24 hours of the decision
- A UR decision is no longer intact and is therefore considered defective if such communication procedure was not followed.
- If UR modified, delayed or denied a request, the reasons of such decision must be communicated effectively.
- A decision of denial cannot be made based on lack of information.
Cases of Concurrent Care and Review
A concurrent care case is a case whereby the applicant is undergoing care while a request for medical treatment or services is being reviewed. In such cases, medical care does not get discontinued without the injured worker’s physician knowledge and an agreed upon care plan by the physician. If a physician has already begun the course of physical therapy before a request had been made, it could not be disrupted and discontinued while the UR is still in process.
Time Frame Guidelines for Utilization Review Process
