Report Examines California Workers’ Comp Medical Dispute Resolution

A new report shows the number of independent medical reviews in California used to resolve medical disputes hit a record low in 2022 as prescription drug disputes continued to decline.

The report from the California Workers’ Compensation Institute also shows that a small subset of doctors continue to generate most of the disputed treatment requests that go through IMR.

California law requires every workers’ compensation claims administrator to have a Utilization Review program to ensure care for injured workers meets evidence-based guidelines in the state’s Medical Treatment Utilization Schedule. Most treatment requests are approved by UR, but in 2012 state lawmakers adopted IMR to allow injured workers to get an independent medical opinion on requests that UR physicians modify or deny.

In its analysis, CWCI found that 127,215 IMR decision letters were issued in 2022 in response to applications submitted to the state, down 4.7% from 133,494 letters in 2021 and down 31.1% from the record 184,735 letters in 2018.

After reviewing medical records and other information provided to support a disputed treatment request, IMR doctors upheld the UR physician’s modification or denial of the service in 91.1% of the 2022 IMRs, down slightly from the record 92.0% uphold rate in 2021, according to the CWCI.

CWCI has issued its analysis as a free report to the industry, “Resolving Medical Disputes: Factors that Drive IMR Volume and Outcomes in the California Workers’ Compensation System.”

The institute has also published an expanded summary of the 2014 – 2022 IMR data in a bulletin that CWCI members and subscribers can find under the communications tab at the CWCI website.

Related:

• Report: California Workers’ Comp Public Self-Insured Claim Volume Rose in FY 2021/22
• California Workers’ Comp Benefits to Increase in 2023
• California Workers’ Comp Independent Medical Review Volume Fell in First Half of 2022

Topics California Workers' Compensation