Report: Sharp Drop in California Workers’ Comp Independent Medical Reviews

A report from the California Workers’ Compensation Institute on the state’s independent medical review process used to resolve workers’ comp medical disputes shows the number of IMR decision letters hit an all-time low in 2021.

The drop comes as pharmaceutical disputes – especially those involving opioids – have continued to decline since the state adopted evidence-based chronic pain and opioid guidelines and a prescription drug formulary, according to the CWCI.

Data for the study was gleaned from more than 1.1 million IMR decision letters issued from 2015 through 2021 in response to applications submitted to the state after a utilization review physician modified or denied a workers’ comp medical service request.

The authors of the CWCI report also used the data to measure shifts in the mix of medical services reviewed and uphold rates by major medical service category; IMR response times; regional variations; the distribution of prescription drug IMRs and uphold rates for various drug categories; the proportion of IMRs involving medical service request modifications among six service categories; and the concentration of IMRs involving high-volume medical providers.

The IMR letter count showed that since peaking at 184,735 letters in 2018, letter volume declined for three straight years, falling to 133,494 letters in 2021.

While some of that decline reflects decreasing claim volume in 2020 – the first year of the pandemic – the study found that much of the decline came after the Division of Workers’ Compensation incorporated chronic pain and opioid guidelines into the workers’ compensation medical treatment schedule in late 2017 and implemented a prescription drug formulary, according to CWCI.

The study’s regional analysis identified areas of the state where 2021 IMR letter volume was high or low relative to each region’s workers’ comp claim volume. Los Angeles County, where workers’ compensation litigation is high, accounted for 24.7% of California’s 2021 workers’ comp claims and 27.6% of the IMR letters, according to CWCI.

CWCI has issued its latest analysis, which can be downloaded on its website.

Related:

• Report: California Workers’ Comp Virus Claims Spiked During December Surge
• Report: California Workers’ Comp Covid Claim Volume Trending Down After Summer Surge
• California Workers’ Comp Hospital Stays Decline as COVID Affects Quantity and Types of Admissions

Topics California Workers' Compensation