How Do Independent Medical Reviews Factor in a California Workers’ Comp Case?

 Posted on March 23, 2024 in Workers' Compensation

When someone is injured at work, they can often get workers’ compensation benefits to help cover the costs of hospital bills, medication, and therapy as well as loss of income resulting from inability to work. Sometimes, an employee’s account of what happened and how he was injured is not enough to prove that he is truly entitled to the benefits. His employer or the employer’s insurance company might try to fight the claims or demand proof of the employee’s claims before they agree to any responsibility. In such cases, an independent medical review (IMR) might be requested. If you are trying to convince your employer or their insurance provider of the severity of injuries you suffered at work, speak with a knowledgeable Morgan Hill, CA workers’ comp attorney about getting an independent medical review.

How Does an Independent Medical Review Work?

If a dispute arises over an employee’s request for medical care, a utilization review (UR) can be ordered. Its purpose is to determine whether someone’s condition truly necessitates the requested care. If a UR results in the employee being denied treatment or offered a modified treatment plan, that same employee can request an independent medical review. He just needs to make sure that the request is submitted within 30 days of receiving the UR determination.

In an independent medical review, all the documentation about the injury is examined. This includes medical records, reports detailing the employee’s condition, treatment plans, medication, and medical recommendations about how he should proceed regarding work following the injury. This medical professional then submits an opinion about the injury and whether the medical care is necessary. This opinion is used to resolve any disputes that the employer’s insurance company might have with the employee regarding whether the items he is seeking compensation for were truly essential.

What Happens With the Findings of an Independent Medical Review?

Once an IMR has issued a decision, it is legally binding. If it determines that whatever treatment was requested is medically necessary, the insurance claims administrator needs to act in accordance. That means that if the treatment was already provided, the insurance company will need to reimburse those costs within 20 days, and if treatment has not yet begun, the claims administrator needs to authorize it within five business days. If, however, treatment is deemed medically unnecessary, it can be denied altogether. If treatment is already underway, it might be stopped.

Schedule a Free Consultation with a Santa Clara County, CA Workers’ Compensation Lawyer

If a workplace injury has forced you to seek treatment and your employer’s insurance provider is questioning it, speak with an experienced Gilroy, CA workers’ compensation attorney. Call Cramer + Martinez at 408-848-1113 to schedule a free consultation.