California Workers’ Comp Independent Medical Review Volume Rose in First Half of 2023

A review of the Independent Medical Review process used to resolve California workers’ compensation medical disputes shows the number of IMR decision letters rose 4.1% in the first six months of 2023 compared to the first half of 2022 after hitting an all-time low high in 2022 – though the number of letters and individual decisions remained below pre-pandemic levels.

That’s according to the review by the California Workers’ Compensation Institute. CWCI’s review encompassed more than 1.3 million IMR decision letters issued from 2015 through June 2023 in response to applications submitted to the state after a Utilization Review physician modified or denied a workers’ comp medical service request.

Institute analysts tallied the number of letters issued each quarter based on the letter date; determined the distribution and uphold rates by medical service category for the disputed treatment requests, as well as the distribution and outcomes of pharmaceutical IMRs by major therapeutic drug group; and calculated the percentage of IMRs associated with high-volume medical providers.

The data show that total IMR volume trended down for four consecutive years (2019-2022), as the number of work injury claims fell during the pandemic and pharmaceutical disputes declined after the state adopted the evidence-based Medical Treatment Utilization Schedule Prescription Drug Formulary and Pain Management and Opioid Guidelines.

After climbing to a record 184,735 letters in 2018, IMR letter volume fell 31.1% over the next four years, falling to 127,215 letters in 2022, according to CWCI.

While IMR decisions were down across all medical service categories, the addition of the Pain Management and Opioid Guidelines into the MTUS in 2017 and the implementation of the MTUS Formulary in 2018 “had a huge effect as prescription drug disputes fell from 47.3% of all IMRs in 2017 to 33.3% in 2022, while the initial data from 2023 show prescription drug disputes fell to 32.6% of the IMRs in of the first half of this year,” a release from the CWCI states.

From 2018 through June of this year, opioids’ share of the pharmaceutical IMRs dropped from nearly one-third to less than one-fourth of all prescription drug IMRs.

As in previous reviews, the data show a small number of physicians continue to drive much of the IMR activity, with the top 1% of requesting physicians (80) accounting for 40.3% of the disputed service requests that underwent IMR in the 12 months ending on June 30 of this year, according to CWCI.

CWCI members and subscribers can find a more detailed summary of IMR experience through June 2023 at www.cwci.org, and Institute members can also access updated IMR slides under the Research tab.

Topics California Workers' Compensation