Independent Medical Review

Signs of Success for Medical Dispute Resolution System

Contrary to criticism, workers' comp legislative reform is working for payers and employees alike.
By: | February 21, 2014 • 3 min read

Reform legislation aimed at reducing frictional costs in California’s workers’ comp system seem to be effective, according to a new report. It says that contrary to some criticism, the new medical dispute resolution system is not “generating wholesale denials of necessary care for injured workers,” according to the California Workers’ Compensation Institute.

“The inability of the adversarial and judicial systems in workers’ compensation to effectively implement the standard of medical care intended by the prior reforms through the adoption of the Medical Utilization Treatment Schedule and utilization review led to the creation of a new medical dispute resolution process: independent medical review,” the CWCI explained in its report, Medical Dispute Resolution: Utilization Review and Independent Medical Review in the California Workers’ Compensation System. “The Legislature determined that medical professionals should decide whether treatment was medically necessary, and that the determination of these issues requires independent and unbiased medical expertise.”

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As part of Senate Bill 863, the new process to resolve medical disputes took effect January 2013 for injuries on or after that date. In July, the process became available for all medical services regardless of the injury date, resulting in thousands of IMR requests.

“Some stakeholders assert that the flood of IMR requests is due to the widespread denial of care by workers’ compensation payors who have programmed their utilization review systems to reject treatment requests regardless of the merits of the request,” the report said.

The CWCI evaluated the process and determined that approximately 94.1 percent of medical treatment requests are approved after the initial internal utilization review and elevated physician-based utilization review with the 5.9 percent forming the potential pool of modified or denied decisions that may be submitted for IMR. Of the elevated physician-based utilization review decisions submitted for IMR, 79 percent have been upheld.

The findings “effectively translate to an overall approval rate of as much as 95.3 percent of all medical treatment requests and a minimum modification/denial rate of 4.7 percent of all medical treatment requests,” the report says. “The fact that such a modest proportion of medical treatment requests are modified or denied belies the notion that UR/IMR produce widespread denials, and provides strong evidence that they are serving as intended, as an exception process to preclude inappropriate and/or unnecessary treatment.”

The researchers also reported the following findings:

  • Of the 919,370 medical treatment requests submitted for elevated utilization review, more than three out of four were approved with pharmacy-related requests accounting for the highest percentage of the utilization review decisions (43 percent) with 74.1 percent approved, 7.2 percent modified, and 18.7 percent denied.
  • Although relatively infrequent, treatment requests for ergonomic evaluation and anesthesia had the highest utilization review approval rates — both 98 percent or above. Complementary and alternative medicine had the lowest utilization review approval rate with 34.4 percent of the requests for those services approved, 14.8 percent modified, and 50.9 percent denied.
  • High-volume procedures such as physical medicine, chiropractic, and acupuncture services had the highest levels of treatment request modifications — 12.6 percent, 16.0 percent, and 21.2 percent respectively.
  • IMR upheld 78.9 percent of all reviewed elevated utilization review decisions while overturning 21.1 percent, with a majority of the utilization review decisions upheld in all 14 medical service categories. Again, pharmacy-related IMR decisions were by far the most prevalent, accounting for one-third of all IMR determinations.
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  • Consultations, laboratory services, and tests and measurement had the highest percentage of overturned utilization review decisions after IMR (50 percent, 34.2 percent, and 35.3 percent respectively).
  • Among the high-volume IMR requests, durable medical equipment, which accounted for 1 out of 10 IMR determinations, had the lowest percentage of utilization review modifications (13.2 percent) while 85 percent of all IMR decisions on physical medicine upheld the utilization review determinations.
Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at [email protected]com.

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.

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That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.

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Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]