Just when you thought you started to understand “utilization review,” Agreed Medical Examiners, Qualified Medical Examiners and all the other catch phrases from the last workers’ compensation reform, along came the Legislature with a new work comp bill in October 2012 that just made things more difficult to get treatment for a work related injury. Late last year, the Legislature passed a new “reform” bill that created a process called Independent Medical Review (IMR) to resolve all medical treatment disputes. This process became effective July 1, 2013 for all dates of injuries which means it applies to any injury regardless of when it occurred and even if you have an award for “life time medical care” from the workers’ compensation appeals board.
So what is IMR and how does it work? How does it affect you and how do you navigate through the process? First, a brief summary of how medical treatment disputes were resolved before IMR became the law.
A treating doctor would recommend a mode of treatment or diagnostic procedure and submit the request to the work comp claim examiners on your case. The claims examiner would then submit the request to a “Utilization Review” (UR) company where a physician would review the request against medical guidelines and then decide if the request should be approved, modified or denied. If approved, you received the treatment or test. If denied, you would then be examined by an AME (if you were represented by an attorney) or a QME (if unrepresented). The doctor would then decide if you should review the treatment and in the majority of cases, the doctor approved the treatment and reversed the UR denial. If the AME or QME agreed with the UR doctor in denying the treatment, the AME or QME could be deposed by your attorney and challenged on their opinion.
IMR eliminates the examination stage after UR denies the treatment. UR still exists as the first stage of review, but if UR denies the treatment request, the injured worker appeals the decision by filing an application for IMR. The application (a one page document) is completed by the claims adjuster and attached to the UR denial. The injured worker has 30 days to file the IMR application with the Administrative Director of the Division of Workers’ Compensation. The application will be reviewed by the AD for completeness and then assigned to Maximus, a company based in Virginia that has contracted with the State to conduct all IMR.
Once Maximus has been assigned the case, they notify the injured worker, his/her attorney and the claims examiner, that the treatment issue has been assigned to IMR and each side has 20 days to submit all “relevant” documentation for review by the IMR doctor. The claims examiner is required to submit all medical reports from the treating physician pertaining to the treatment dispute and the UR decision.
Maximus assigns the case to a doctor who specializes in the specific treatment request (i.e.: orthopedics, cardiology, etc.). The Maximus doctor will review the material submitted, apply medical evidence guidelines approved by the Division of Workers’ Compensation, and issue a decision either upholding or reversing the UR denial.
The IMR doctor does not examine or interview you before rendering a decision but simply reviews all of the material submitted. The doctor is anonymous and may not be deposed by either party after rendering a decision. The IMR decision is final and essentially not subject to appeal. It is binding for one year and cannot be reconsidered unless you prove a change in circumstances in your condition.
Because there is no contact between you and the IMR doctor, it is critical that the IMR doctor be provided with all relevant medical reports and records. Most importantly, your treating doctor needs to submit a report that not only states you “need” the test or treatment, but the doctor must set forth the evidence based guidelines which justify the treatment in question.
Here are two examples involving different injured workers with similar shoulder injuries where the treating physician recommended an MRI which was denied via UR. After IMR, one was reversed and the other affirmed. The difference was the reporting submitted by the treating doctor and how the doctor justified his recommendation with appropriate guidelines. The IMR decision affirming the denial stated: “The most current note indicated 4/5 muscle weakness but did not indicate location. There was no mention of a shoulder deficit or lesion. The patient has not completed physical therapy. There are no concerning findings on physical exam and the medical records do not provide any consideration for surgery. The Guidelines indicate that magnetic resonance imaging (MRI) is not recommended for evaluation without surgical indications. The submitted records do not show that the patient has completed or failed a trial of conservative care. The criteria for shoulder MRI have not been met.” The IMR rationale in the decision overturning the UR denial stated: “The employee’s medical records showed persistent shoulder pain with repetitive motion, resistant to six weeks of conservative therapy with medicals and physical therapy. Since the employee suffered a traumatic injury with poor improvement after six weeks, an MRI is consistent with ACOEM guidelines.”
These examples were taken directly from the Division of Workers’ Compensation website and are not fictional. They demonstrate that it is possible to win at the IMR level but it takes some help from your treating doctor. IMR decisions are based on evidence based guidelines and not merely an opinion from your doctor that the treatment will help. If your doctor doesn’t justify his/her recommendation, the chances are slim you will succeed at IMR. If you don’t succeed at IMR, you will not receive the treatment necessary to get better and return to work. .
There is an expression in law that says, “He who represents himself has a fool for a client.” The legislature made it more difficult for you to obtain appropriate treatment for your injury. IMR is another obstacle in your way to recovery from an injury. Be smart and use all the tools available to you in overcoming these obstacles. You trained hard to become a firefighter. Don’t let your career be jeopardized because of your injury and inability to get properly treated. Consult with an attorney knowledgeable in representing safety members injured on the job. In the meantime, stay safe and healthy.
By Robert Sherwin – Lewis, Marenstein, Wicke, Sherwin & Lee, LLP