In May 2023, the California Workers’ Compensation Institute (CWCI) published a comprehensive report on Independent Medical Reviews (IMR). Since it was put into place by California regulators, the IMR system in California has played a major role in workers’ compensation. The report from the CWCI assesses the efficacy of the state’s Independent Medical Review process. The system has now been in place for around ten years ago. Here, our Fresno workers’ compensation defense law firm highlights the key things to know about the May 2023 CWCI report.

Background: What is Independent Medical Review (IMR) in California Workers’ Compensation?

Independent Medical Review (IMR) in California workers’ compensation is a process where medical professionals unaffiliated with insurance companies review and resolve disputes concerning the medical treatment of injured workers. In other words, IMR is a non-judicial process that is used to resolve disputes over medical issues for injured workers.

Established by the California Division of Workers’ Compensation, IMR is designed to help ensure that decisions are based on medical necessity rather than insurance considerations. If an insurer denies, modifies, or delays a treatment recommendation, the injured worker can request an IMR.

The Goal of the IMR Study From the California Workers’ Compensation Institute

This study aims to analyze the factors driving high volumes of Independent Medical Review (IMR) letters in California’s workers’ compensation system. It explores the discrepancies between this system and other healthcare delivery models while shedding light on a small group of providers contributing disproportionately to the state’s workers’ compensation IMR decisions.

What the CWCI Found in its Independent Medical Review Study

When Independent Medical Review (IMR) was introduced, it was anticipated that letters disputing Utilization Review (UR) denials or modifications would be low and diminish over time as medical providers and payers adapted to the system’s permitted care types. Contrarily, IMR letter volume soared from 143,983 in 2014 to a record 184,735 in 2018 before declining by 31% to 127,215 letters in 2022—a decline that was largely due to the MTUS Formulary implementation reducing prescription disputes and the COVID-19 pandemic curtailing workers’ compensation claims.

The study also drew comparisons with Texas’ IMR process, revealing California’s IMR letter volume was a staggering 92 times greater, highlighting significant disparities between the systems. Notably, the CWCI found that an IMR generally upholds the initial determination that is under review. For example, in 2022, the IMR uphold rate was more than 91%. Over the past decade, the average uphold rate has hovered right around 90%.

Contact Our Fresno, CA Workers’ Compensation Defense Law Firm Today

At Yrulegui & Roberts, our Fresno workers’ compensation defense lawyers have the legal experience that you can trust in complex cases. If you have specific questions or concerns about IMRs in California, we are here as your professional resource. Call us now or contact us online to arrange your completely confidential consultation. Our firm provides workers’ compensation defense services in Fresno, Fresno County, and all across the surrounding region in California.