Gary Rischitelli, MD, JD, MPH, FACOEM is the national Medical Director for Conduent’s workers compensation services and medical claims management solutions business group.
Since 2013, the California’s workers compensation system has resolved utilization review (UR) disputes regarding medical necessity through a process called independent medical review (IMR).
In theory, IMR is an ideal alternative medical dispute resolution system. Putting medical decisions in the hands of medical professionals reduces the costs and delays of litigation.
Conduent monitors and analyzes our clients’ IMR outcomes with an eye toward quality control and improvement. We recently completed an analysis of 595 California IMRs conducted over a three-month period earlier this year. Looking at the IMR experiences and comparing the characteristics of our UR reviewers and the IMR reviewers, we believe there are several areas of the California IMR process that could be improved and other states considering similar processes should follow.
Issues surrounding state licensure and specialty match
Our examination of 595 California IMR treatment determinations from April through June of this year revealed that 92% of UR determinations were upheld and 8% were overturned.
The reason for non-certification of a treatment most often cited by UR was that it did not meet medical guidelines (67%). Conversely, the reason most often cited by IMR for overturning the UR decision was that the treatment did indeed meet guidelines (56%). Clearly, the reviewers differed in their opinions of what meets the Medical Treatment Utilization Schedule (MTUS) guidelines.
Taking a closer look, our analysis suggests that IMR reviewers tend to interpret guidelines more broadly, are content with a lower certainty of medical evidence, and/or often do not consider the prior treatment history in their decisions. We identified that 16% of IMR decisions were clearly erroneous or appeared arbitrary—that is, the decision lacked a persuasive medical rationale. Additionally, we discovered that 27% of IMR decisions misinterpreted or misapplied the MTUS guidelines.
Our analysis also showed a significant difference in the proportion of clinical peer reviewers who were licensed in California—nearly 100%—versus IMR physicians at 70%. Although California does not require clinical peer reviewers to be licensed in the state, as a best practice Conduent requires same-state licensure. We have found licensure is a good indicator of familiarity with the home state’s medical community, standards of care, workers compensation system, and preferred treatment guidelines.
Another Conduent best practice is that the clinical peer reviewer be of the same or similar specialty as the requesting provider for the utilization review. However, our California analysis revealed many cases where despite matching the clinical peer reviewer specialty with the requesting physician, the IMR case was subsequently assigned to a primary care provider, such as a family practice (FP) internal medicine (IM), occupational medicine (OM) or emergency medicine (EM) physician. Not surprisingly, we identified a much higher frequency of incorrect IMR overturns when reviewers were not specialty matched—69% not matched vs. 27% matched. We also found that primary care reviewers had a higher proportion of incorrect overturns (67%) compared to the entire pool of reviewers (44%).
3 more takeaways
California is a bellwether for policy innovation. Its IMR program could serve as an example to other states’ workers comp medical dispute resolution systems by transforming its limitations into strengths.
In our opinion, by addressing the quality of the IMR review through licensing and specialty matching, the process will only improve. As our analysis revealed, almost half (44%) of IMR overturns were deemed incorrect or flawed—not much better than a coin flip.
An uncommon feature of California’s IMR process is that the IMR reviewers are anonymous. In contrast, clinical peer reviewers are required to sign both their reports and an attestation that they are qualified to render an opinion and that they have no conflicts of interest. The IMR
reviewer’s anonymity prevents meaningful review or accountability by third parties or the public. IMR reviewers should disclose their identities, and be held to the same standards of accountability as any other medical professional involved in the care of injured workers.
Finally, the IMR system provides no avenue for appeal or reconsideration when the determination appears to be incorrect, arbitrary or based on an incomplete or inaccurate assessment of the medical records. IMR could easily incorporate an appeal process in select cases similar to the appeal process provided during utilization review where the case is referred to a second reviewer with the same specialty as the requesting physician. This opportunity for appeal or reconsideration is important due to the inherent variation in individual reviewer’s attention, knowledge, experience, or unconscious bias.