For some people, the workers’ compensation claim process goes smoothly and swiftly, while others may encounter delays and obstacles. However, even those in the latter category can ultimately achieve successful outcomes with the right help.
One common workers’ comp issue arises when the claims administrator and your treating doctor disagree about matters such as your disability rating or medical necessity of treatments. While workers’ compensation cases filed prior to 2013 may still use the qualified medical examiner (QME) process to resolve these disputes, workers injured during or after 2013 will go through the independent medical review (IMR).
When to ask for a review
When a claims administrator wants to cut benefits based on the belief that recommended treatment is not medically necessary, you may contest this decision by requesting a review. The reviewing doctor will examine medical records and evaluate the appropriateness of the treatment based on currently accepted treatment guidelines. The doctor will not conduct a physical examination.
Requirements for the IMR process
California law sets out some strict requirements for reviewer selection. An independent medical review organization (IMRO) under the auspices of the Division of Workers’ Compensation Medical Unit must run the process. These provisions intend to ensure that IMRs lack bias, addressing the problems that arise when insurance companies select their own physicians to conduct examinations.
The IMR process also aims to reduce the timeline for review, which under the previous QME process could take as much as over a year. After you request the IMR, the IMRO will notify you, your physician and the claims administrator as to what information it needs everyone to submit. Once the IMRO receives all the documentation, it has 30 days to issue a decision.
Appealing an IMR decision
In some limited cases, you may appeal an IMR result to a workers’ compensation judge. The judge will not render medical decisions; he or she will not address whether the IMR assessment of medical necessity is correct. However, the judge may modify or overturn a decision if he or she finds a mistake of fact, fraud or a conflict of interest.
To learn more about these matters, please see our page on the importance of having a workers’ comp attorney on your side.