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In California 10% of denied treatment is overturned on appeal
#1
Report released today on results of comp cases where denied treatment was appealed (Independent Medical Review).
10% of the denials in 2014 & 2015 of all types of treatment were overturned by IMR.
In 2015 30% of denials of evaluation and injury management were overturned on appeal via IMR.

Details in the 40 page report are here:

http://www.dir.ca.gov/dwc/imr/reports/20...Report.pdf
Reminder :
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THANKS FOR POSTING.
 
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#2
Thank you for the post 1171.

I hope when people read the report they do so with full knowledge of what is going on in the UR and IMR system. Some may view the above and believe most denials are justified. In my opinion this is not the case. Many patients get denials that are based upon guidelines that do not fit their complex condition and/or denials are being done based upon missing information.

I can successfully overturn most UR denials through the UR companies internal UR appeal process. However I have yet been able to overturn a UR denial through IMR. Why is that?

I developed a way to successfully overturn UR denials by using medical treatment guidelines and patients medical history. My appeal process should work the same with IMR as the treatment guidelines are the same. I soon realized that these two entities are not the same. What I have seen is many IMR reviewers just regurgitate the rational and reasoning for the original UR denial.

Also, I have noticed my IMR cover letters which contains patients history and rational as to why the request was warranted is never listed among the documents received by the IMR doctor. I tried to find out if for some reason could MAXIMUS choose what I sent to them gets forwarded to their reviewers? I have yet to receive an answer from MAXIMUS. I was told when documents are sent in they go to a person who decides what should be sent to the IMR reviewer, but they would not transfer my call or allow me to speak to one of these decision makers.

And many IMR reviewers do not appear to be actually reading the medical records I send. I know this because I have sent records that address the rational used to deny but they were ignored. One example of this is if a denial was based upon patient had not yet attempted physical therapy and conservative treatments like x,y, first and I send records that show the patient had previously done all of this, however the IMR reviewer used same rational as a means to deny even though medical records state different. I believe many IMR reviewers are not reading records sent to them.Yes this is a reason to take the IMR to a judge however this takes time and usually an attorney. If the attorney is successful then the patient may receive yet another IMR review, where chances are high the same thing could happen again. This is the definition of insanity.

Another problem with UR and IMR is that doctors do not get paid for their time to write an appeal (that I am aware of). This is the biggest problem with the CA UR/IMR process. Many applicant attorney's are now systematically sending in an IMR request after every client gets a denial but how many are reviewing the denial and digging through their clients file to get records to address the reason for the denial and also submitting rational and medical treatment guidelines that show the request is necessary? I only know of a few who do this and I showed them how. They are essentially working for free and I do not see how this could be cost effective in the long term. The same with doctors offices, most do not appeal UR denials through internal UR process and IMR by taking the time to address the reasons for denial and provide appropriate medical treatments guidelines. Some are not very familiar with the CA work comp system and would not know how to do this. Again they do not get reimbursed to appeal UR denials or to send in IMR appeals. This is a big, big problem.

The UR and IMR system sounds good on paper. If you have ever been in the system and actually had to put fourth effort to do an appeal you will find it can be extremely time consuming and a skill set is needed. I developed a system to appeal these denials out of pure necessity for myself and to help other patients. Most injured workers do not have this skillset or an advocate to help them and it is absolutely heartbreaking for me to read post after post about their denials and how it affects them.

I hope one day I can do something to voice my opinion about these problems and my ideas on how to make this system more fair.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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