UPDATE: INDEPENDENT MEDICAL REVIEW INDEPENDENT BILL REVIEW MEDICAL TREATMENT UTILIZATION SCHEDULE

Commission on Health and Safety in Workers’ Compensation March 26, 2015 Rupali Das, MD, Executive Medical Director, DWC

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INDEPENDENT MEDICAL REVIEW

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IMR Update • New three-year contract awarded

• http://www.dir.ca.gov/dwc/IMR/IMR-Contract/IMR-Contract.pdf

• 2014 IMR decisions public posting • http://www.dir.ca.gov/dwc/IMR/IMR-Decisions/IMR_Decisions.asp

• Continuous process improvements • Track metrics, random review of final decisions

• Report issued in 2014 • http://www.dir.ca.gov/dwc/imr/reports/2014_IMR_Annual_Report.pdf.

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IMR Highlights, 2015 • IMR applications are filed for between 1% and 5% of all

medical treatment requests • IMR decisions are issued less than 30 days after receipt

of complete medical records • The largest category of IMR requests are for medications

• 42% of 2014 IMR decisions: pharmaceuticals • 26% of pharmaceutical IMRs: narcotic pain medications

• Overturns UR decisions in 12% of final determinations • Disproportionately more IMR cases than injury claims

were filed in the Los Angeles area

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IMR Process 5

SUPPORTING DATA For IMR Highlights

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Most treatment requests are approved

• 550,000 – 650,000 new WC claims filed every year requiring medical treatment.

• 2014: • 26.2 million treatment request bills reported to DWC’s Workers’

Compensation Information System for 2013 date of service (all dates of injury).

• 486,000 treatments disputed through IMR (high estimate) • 187,000 IMR applications, 145,000 IMR final determinations,

2.6 treatments per IMR letter.

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2014 disputed treatments with IMR FDLs compared to 2013 paid medical bills

0

5

10

15

20

25

30

486 Thousand 26.2 million

2014 estimated number of IMRdisputed treatment issues based onIMR Applications and an average of2.6 Treatment Issues per IMR Final

Determination Letter.

2013 date of service medical bill linesfor all dates of injury from WCIS data

Mill

ions

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Treatment Requests Approved vs Denied/Modified

CWCI’s Data: 2014 Preliminary IMR Decision Results

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Approved by UR

94.1%

IMR Eligible 5.9%

Approved After UR or Ovrtn in

IMR 94.6%

Denied or Modified afte

UR/IMR 5.4%

IMR Decisions Issued Less Than 30 Days After Medical Records Received

*Data available to date; March data is incomplete

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2014 IMR: Pharmaceutical Issues Dominate

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% Of All Treatment Decisions, N=275,476

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Facilities/Home Health Care

Psychology/Psychiatry

Evaluation & Mgmt

Acupuncture/Chiropractic

Radiology

Service Category Not Avail.

Surgery*

Diagnostic Test

Equipment

Miscellaneous

Therapies (PT/OT)

Pharmaceuticals

2014 Pharmaceutical IMR Decisions: Top Drug Classes, Random Sample

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0%

5%

10%

15%

20%

25%

30%

Random sample of 780 pharmaceutical IMR decisions from 2014.

Outcomes in 2014 IMR Final Determination Letters

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Overturn N=9,098 (6%)

Partial Overturn N=8,222

(6%)

Uphold N= 127,324

(88%)

2014 IMR Final Determination Letters, N=144,644

2014: More IMR Cases than Injury Claims in Los Angeles Region

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0% 10% 20% 30% 40%

SACRAMENTO VALLEY (North)(N=2,507)

NORTH STATE-SHASTA (N=3,333)

EASTERN SIERRA FOOTHILLS(N=3,715)

SACRAMENTO VALLEY (South)(N=7,671)

SAN DIEGO (N=9,104)

CENTRAL COAST (N=13,608)

CENTRAL VALLEY (N=18,499)

BAY AREA (N=34,471)

INLAND EMPIRE (N=37,030)

LOS ANGELES (N=53,641)

% of IMR Closed Cases% of WCIS Claims

ADDITIONAL IMR INFORMATION

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Monthly IMR Application Volume Steady

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2014 IMR Applications: 75% Unique

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5000

10000

15000

20000

25000

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

Unique Applications in 2014

Unique Received

2014 IMR Applications: 62% Eligible

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5000

10000

15000

20000

25000

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

Eligible Applications in 2014

Unique

Eligible

Received

All IMR Applications: 88% Closed

Applications received January 1, 2013 through March 11, 2015

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2014 IMR Closed Cases

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Final Determination

Letter N= 144,644, (77%)

Ineligible N=31,787 (17%)

Terminated N=11,541

(6%)

2014 Closed Cases, N= 187,972

11% 15%

2%

38%

28%

6%

CNC No Signature

No Signature & No UR No UR

Untimely Other

CNC=Conditionally non-certified

Most Common Reason for Ineligible IMR: UR Decision Not Submitted with Application

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Average 2.6 Treatment Issues per IMR Final Determination Letter

1 Issue 44%

2 Issues 20%

3 to 5 Issues 27%

5 to 10 Issues 8%

10+ Issues 1%

2014 Average 2.6 Issues per IMR with FDL Max Issues for single IMR FDL 37

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IMR Most Likely to Overturn UR For Evaluation and Management (Physician Consult)

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0% 20% 40% 60% 80% 100%

Facilities/Home Health Care

Psychology/Psychiatry

Evaluation & Mgmt

Acupuncture/Chiropractic

Radiology

Service Category Not Avail.

Surgery*

Diagnostic Test

Equipment

Miscellaneous

Therapies (PT/OT)

Pharmaceuticals

All Categories

Overturned UR (%) Upheld UR (%)

Most Injuries Date from 2012, 2013 24

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

Closed IMR Applications

2014 IMR Closed Cases: 70% of Filed by Representative

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Injured Worker Representative

N=132,012 (70%)

Injured Worker No

Representative N=55,960

(30%)

2014 Closed IMRs, N =187,972

Medical Specialties of IMR Physician Reviewers, 2013

0% 5% 10% 15% 20% 25% 30% 35% 40%

Psychology (N=65)

Chiropractic (N=76)

Psychiatry (N=51)

Neurology (N=57)

Anesthesiology (N=153)

Family Medicine (N=252)

Internal Medicine (N=288)

Orthopedic Surgery (N=555)

Occupational Medicine (N=680)

Physical Medicine and Rehabilitation (N=1,311)

% of IMRs FDLs

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IMR FDLs: 3,723

IMR Provides Medically Necessary Care and Prevents Harmful Procedures • CM13-0054595: Overturn, detoxification program

• CM14-0029944: Overturn, evaluation for function restoration program

• CM14-0011989: Partial overturn, narcotic analgesic

• CM14-0049819: Uphold, lumbar fusion

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INDEPENDENT BILL REVIEW (IBR)

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IBR Process – Decision issues within 60 days of Assignment

Initial Bill Submission for medical treatment or medical-legal services

Second Bill Review by claims administrator if dispute over amount paid

Final Determination Letter Fee reimbursed if provider prevails

Maximus assigns eligible case to Coding

Expert

Maximus receives documents from claims administrator

Provider files for Independent Bill Review (IBR) if dispute not resolved. Filed either by

mail or online with $195 filing fee

Maximus conducts preliminary review for eligibility

Ineligibility Determination for: • Incomplete application • No payment of fee • No second bill review • Dispute not under fee schedule • Service not authorized

If eligible, Maximus requests response from claims administrator

IBR may be withdrawn by provider if dispute resolved

Provider may consolidate similar requests for one

decision

IBR Applications, 2013 - 2014

IBR Applications Through December 2014: N=2,969

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95 113 113

126 121 129

195

132 140

217

167

133 130 125

164

239

173 185

171

0

50

100

150

200

250

300

1,019

249 197 134 122 79 76 70 4 2 0

200

400

600

800

1,000

1,200IBR: Physician Service Most Common

IBR Applications Through December 2014: N=2,969

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http://www.dir.ca.gov/dwc/IBR/IBR_Decisions.asp

IBR Decisions with a Single Service: Most Decided in Favor of Provider

1439 out of 1952 IBR decisions thru December 2014 disputed payment for a single service

Decided in favor of

Provider, N= 887 (62%)

Decided in favor of Claims Administrator,

552 (38%)

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Average IBR Award Varies by Service

$0$1,000$2,000$3,000$4,000$5,000$6,000$7,000

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MEDICAL TREATMENT UTILIZATION SCHEDULE Update Plans

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Update Plans

• Evaluating Medical Evidence • Guideline for the use of opioids to treat

non-cancer pain • Guideline for the treatment of chronic

non-cancer pain • Other clinical topics and “body chapters”

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Resources

• Independent Medical Review • http://www.dir.ca.gov/dwc/IMR.htm

• Independent Bill Review • http://www.dir.ca.gov/dwc/ibr.htm

• Medical Treatment Utilization Schedule • http://www.dir.ca.gov/dwc/MTUS/MTUS.html

• Forms • http://www.dir.ca.gov/dwc/forms.html

• DWC Medical Unit • http://www.dir.ca.gov/dwc/MedicalUnit/imchp.html

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