Independent Medical Review in workers compensation
A large part of the workers compensation case is making sure that the injured worker receives all the medical treatment he/she needs. When an injured worker’s treating physician believes that the injured worker needs a specific type of medical treatment, that physician submits a Request For Authorization of that medical treatment to the workers compensation insurance company. The workers compensation insurance company sends the Request for Authorization to its Utilization Review department. The UR department has 14 days to respond to the Request for Authorization. The UR department can either authorize payment for the medical treatment requested or deny authorization for payment. If the treating physician doesn’t get authority from the workers compensation insurance carrier, then the physician will not provide the medical treatment to the injured worker. If the insurance company denies authorization of the physician’s request, then the injured worker can apply for Independent Medical Review of the insurance companies decision to deny the authorization of medical treatment. The Independent Medical Review department has medical experts and they will review the injured worker’s medical records to make their own decision of whether the requested treatment is necessary.
The Utilization Review and Independent Medical Review process is a new one in workers compensation and is already having a great impact on injured workers. You must ensure that the IMR process is conducted in the correct way or you may lose your rights to an appeal. Our office is experienced in handling IMRs. The next case shows some of the requirements in order to preserve your right to an appeal to the IMR.
In the November 20, 2014 decision regarding Timothy Bodam v. San Bernardino County/ Department of Social Services legally uninsured, the Workers Compensation Appeals Board stated the following:
(1) A defendant is obligated to comply with all time requirements in conducting a utilization review; (2) A utilization review decision that is timely made but is not timely communicated is untimely; (3) when a UR decision is not valid, the Workers Compensation Judge may determine if the requested medical treatment is necessary.
In this case, the Workers Compensation Appeals Board held that the insurance company did not timely respond to the employee physician’s request for authorization of medical treatment. The Workers Compensation Appeals Board required the insurance carrier to provide the requested treatment.