workers compensation independent medical reviewsWorkers Compensation Independent Medical Reviews

Across the country more and more workers compensation organizations are utilizing Workers Compensation Independent Medical Reviews to keep claims on track, and to decrease unnecessary expenditures as they relate to legal proceedings.  Workers compensation organizations who work with a quality Independent Medical Review organization have seen claims issues and disagreements taken out of the court setting, and brought into the medical setting.  This is yielding both cost savings for workers compensation organizations, as well as higher satisfaction for injured workers who are submitting claims, as they know that there is an option for any claim which is denied to be reviewed by an independent, objective physician.

Independent medical reviews, (which can also be called claims reviews, case reviews, or physician advisor reviews) for workers compensation ensure that there is a cost-efficient non judicial way to address disputes between injured workers and workers compensation organizations.  An independent medical review can be utilized in the workers compensation setting when a request for medical treatment is delayed, modified, or denied by a workers compensation claims administrator on the grounds that treatment does not meet medical necessity. If the injured workers disagrees with this determination, they can request that an independent medical review (IMR) of that decision be made.

During the workers compensation independent medical review process, the claim will then be reviewed by an objective, qualified, third party physician who will then make a determination to agree with the initial finding, or disagree with the initial finding.  This allows the workers compensation organization to process claims disputes outside of the courtroom setting, saving money, and also allows the patients a “second opinion” on their case that is timely, objective, and rendered by a highly qualified physician whose treatment expertise matches the intricacies of the workers case.

Workers Compensation Savings in California

In January of 2013 the State of California completed an extensive overhaul of the State’s workers compensation system as part of Senate Bill 863.  As part of this reform, increased compensation for permanent disability benefits was put into effect, and, as stated by the California Department of Industrial Relations “an independent medical review program in which medical experts determine the necessity of treatment using evidence-based medicine” was put into place.  To date, these changes have yielded a 3.3% reduction in 2014 medical costs, a trend which according to the Workers Compensation Insurance Rating Bureau of California, may result in savings to employers.

“There is less litigation over the bills, because medical providers know what they will be paid” said Christine Baker, Director of the Department of Industrial Relations, which oversees the Division of Workers Compensation in Oakland, CA.  The new medical review process is certainly an important factor in the decrease of litigation related to workers compensation claims according to Government reports.  About 180,000 independent review requests were filed in 2014, but 87% of the cases upheld a utilization review denial or modification of treatment.

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