When Are Independent Medical Reviews Used in California Workers’ Comp Cases?

 Posted on April 12, 2023 in Workers' Compensation

People who are injured while working will usually be able to receive workers' compensation benefits, which will address issues such as the costs of their medical treatment, the income lost while recovering from an injury, and job displacement. However, the process of obtaining workers’ comp benefits is not always straightforward. In some cases, disagreements may arise between an injured worker and their employer or an insurance provider over the medical treatments a person should receive. In such cases, independent medical reviews (IMRs) may be used by the California Division of Workers’ Compensation (DWC) to help resolve these disagreements.

What Is an Independent Medical Review?

An independent medical review is a process that is used to resolve disagreements between injured workers and workers' compensation insurance companies about the treatments that should be provided and whether certain treatments are medically necessary. In an IMR, a medical professional will review a request for treatment and medical records and documentation about a patient's condition and provide an opinion on whether the requested care is medically necessary.

How Does the IMR Process Work?

If a disagreement over medical treatment arises, a utilization review (UR) may be performed to determine whether treatment is medically necessary. If medical treatment is denied or modified following a utilization review, the injured employee can request an independent medical review. An application for an independent medical review must be submitted within 30 days after the injured worker received a written utilization review determination.

After receiving an IMR request, the administrative director (AD) of the DWC will review the application to determine whether the dispute is eligible for an independent medical review. If the dispute is eligible for review, it will be assigned to a reviewer. In regular reviews, documentation of the case must be provided to the reviewer within 15 days, and a reviewer will be required to make a determination within 30 days. If a case is expedited because a doctor has stated that the injured employee needs treatment to address serious issues that are an imminent threat to the patient's health, documentation must be provided to the reviewer within 24 hours, and if treatment has not yet been provided, a determination must be made within three days. If treatment had already been provided, the reviewer will have 30 days to make a determination.

Decisions made by independent medical reviewers will be binding on all parties. If the reviewer determines that the treatment is not medically necessary, then the treatment may not be provided, or ongoing treatment may cease. However, if treatment is determined to be medically necessary, the claims administrator must implement this decision. If treatment had not yet been provided, the claims administrator must authorize it within five business days after the decision was made. If treatment had been provided, the claims administrator will be required to reimburse the doctor or medical provider for the services within 20 days.

If an injured worker disagrees with the determination made during an IMR, they can file an appeal with the Workers’ Compensation Appeals Board (WCAB). Appeals must be filed within 30 days after the final determination was made. These appeals will not address whether treatment is medically necessary. Instead, they may address issues such as fraud, conflicts of interest, obvious factual errors, or discrimination based on factors such as race, sex, religion, sexual orientation, or disability.

Contact Our Hollister Workers' Comp Lawyers for Independent Medical Reviews

Navigating the workers’ comp system in California can be challenging, especially when a dispute arises over the necessity of medical treatment. It is crucial for injured workers to understand their rights and options in these situations, including when they can request independent medical reviews or appeal determinations made by reviewers. At Cramer + Martinez, our San Benito County workers' compensation attorneys can provide effective representation for injured workers, helping them ensure that they receive the proper benefits. Contact us at 408-848-1113 to schedule a free consultation today.

Sources:

https://www.dir.ca.gov/dwc/IMR.htm

https://www.dir.ca.gov/dwc/IMR/IMR_FAQs.htm