Independent Medical Review (IMR)
An Independent Medical Review (IMR) is a practice that is employed when a dispute around medical treatment arises during the workers’ compensation process. After filing a claim, the doctor treating you will request authorization of specific medical treatments to your insurance. The insurance company will then complete a Utilization Review to determine if the treatments requested are necessary. If the doctor performing your Utilization Review determines the treatment requested is unnecessary, they will deny treatment. In this case, you may be able to request an Independent Medical Review to contest the decision. An experienced Sacramento workers’ compensation attorney can help you understand what occurs during an IMR, who can request an Independent Medical Review, how to request an Independent Medical Review, and determine if your claim is eligible for an IMR. If you need help seeking an Independent Medical Review, contact us at Sacramento Workers’ Compensation Attorneys, P.C. We can help you through the process.
During the Independent Medical Review examination, an independent medical expert will review your medical records and other documents applicable to your condition. Independent medical experts are appointed by a for-profit corporation known as Maximus Federal Inc., who is contracted by the California Department of Insurance. The reviewing physician never examines you in person or discusses your condition with you. You do not have the right to meet them or discuss your symptoms in your own words.
They prepare a report which is sent to you, the insurance company, and the insurance commissioner. The insurance commissioner issues a final report to the California Department of Insurance explaining the recommendation.
There are many problems with the Independent Medical Review system. Reviewing doctors are paid a flat fee for every case they review. This means the medical reviewer is not paid based on the amount of time spent reviewing the claim. The only distinction in the fee is if the request is pharmacy or non-pharmacy related and whether the claim is expedited or not.
- Standard Independent Medical Reviews (non-pharmacy-only): $390
- Standard Independent Medical Reviews (pharmacy-only): $345
- Expedited Independent Medical Reviews (non-pharmacy-only): $515
To request an Independent Medical Review, you must first complete a Utilization Review and been denied treatment for your workers’ compensation injury. The injured employee can request an Independent Medical Review, or they can designate an appointee such as:
- An attorney
- A parent, guardian, conservator, relative, or friend
- A physician
There are two Independent Medical Review processes (UR-IMR (Labor Code §§ 4610.5 and 4610.6) and MPN-IMR (Labor Code § 4616.4)) described under California law. UR-IMR is an Independent Medical Review made available to injured workers after they have completed and been denied medical treatment during a Utilization Review. MPN-IMR is an Independent Medical Review available to injured workers treated in a Medical Provider Network.
To request an Independent Medical Review, you must complete an Independent Medical Review application form and send a copy of your Utilization Review decision letter within 30 days of acquiring the decision. If your Utilization Review was expedited, you must include a physician statement addressing the reason for an expedited review. Lastly, you mail the above information to:
DWC – IMR
c/o Maximus Federal Services, Inc.
P.O. Box 138009
Sacramento, CA 95813-8009
Once your application is received, it will be reviewed to determine eligibility for an Independent Medical Review.
Workers’ compensation claims are eligible for an Independent Medical Review if:
- A claim was delayed or denied for a medically necessary and regularly covered treatment,
- A claim was denied for emergency treatment, or
- A claim was denied for investigational or experimental treatments.
Workers’ compensation claims are ineligible for an Independent Medical Review if:
- Your Independent Medical Review application was not filed on time,
- A claim was denied because the insurance contract does not cover the treatment, or
- The liability of the claim is still being disputed.
What can Sacramento Workers’ Compensation Attorneys, P.C. do?
There are still options if you are denied treatment after participating in an Independent Medical Review. Our attorneys can help you understand what occurs during an Independent Medical Review, who can request an Independent Medical Review, how to request an Independent Medical Review, and determine if your claim is eligible for an Independent Medical Review. If you are wondering how an Independent Medical Review can affect your workers’ compensation case, contact an attorney at Sacramento Workers’ Compensation Attorneys, P.C.