Surprise or No Surprise? IMR Requests Far Outnumber IBR Requests

| | Utilization Review

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IMR and IBR

As of August 2014, injured workers had submitted 188,864 requests for independent medical review (IMR) in the state of California. Compare this to the number of requests submitted for independent bill review (IBR) in the same state: 2,827, as of November 2014.

State officials were shocked by these numbers, according to an article published at WorkCompCentral. George Parisotto, of the California Division of Workers’ Compensation (DWC), said he and the rest of his organization expected IBR requests to outpace IMR requests.

But were those expectations logical? Given the purpose of IMR and IBR – as well as the rules and regulations surrounding each – it makes sense that more people turn to IMR than to IBR.

Why IMR and IBR Exist

Requests for workers’ compensation medical treatment that are not immediately authorized must go through utilization review. In California, when a UR provider denies or modifies a treatment request, the injured worker can ask for their case to go to IMR. When the case goes through IMR, it is reviewed by an independent physician, whose job is to decide if the requested treatment is medically necessary. The IMR physician may overturn, uphold or modify the UR provider’s decision, depending on his findings.

The IBR process, on the other hand, is designed to solve billing disputes, rather than medical disputes. If a medical provider, copy service, interpreting service, or other service, disagrees with the payment they receive for services rendered, they can request a second review of the bill. If the provider disagrees with the results of the second review, then the provider can request IBR through the DWC.

Application Fees and Malpractice Worries: Why IMR Is Much More Common Than IBR

To understand why IMR occurs much more often than IBR, consider both processes. IMR is conducted in response to a UR provider’s denial or modification of a treatment request. It makes sense that many injured workers who find their treatment denied will request IMR.

IBR is conducted in response to billing disputes and can only be requested after a claims administrator reviews a bill for the second time. The second review sometimes resolves billing disputes, rendering IBR unnecessary. Moreover, IBR costs money — $250 for each IBR claim. This may dissuade many from requesting IBR. IMR, on the other hand, is free for injured workers; the insurance carrier is required to pay the IMR costs. Thus, injured workers often have little or no reason not to pursue IMR when treatment requests are denied.

Another compelling factor is that applicant attorneys are required by law to act in the best interests of their injured worker clients. This usually means that in the event of adverse treatment decisions by UR providers, they must request IMR on behalf of injured workers. If an attorney fails to request IMR, she could potentially be liable for legal malpractice and could face serious consequences. There is no analogous malpractice threat in cases involving IBR. The only consequence of a provider not requesting IBR is that the provider’s bill will not be paid. Thus, it makes sense that so many more IMR claims occur each year: applicant attorneys often believe they have to file those claims.

SB 863 brought about massive reforms. And the impact of many of the reforms was not easy to predict; hindsight is always 20/20. But given the motivations for requesting IMR and IBR, as well as the costs, rules and regulations surrounding each process, the DWC should probably have anticipated that there would be more IBR claims than IMR claims.

Tom Swiatek

As Assistant Vice President of Regulatory Services and General Counsel, Tom Swiatek draws on his experience as an insurance attorney on both the general liability side, as well as on workers’ compensation matters. As a Workers’ Compensation Section Member, Tom is leading the discussion with respect to the regulatory challenges and opportunities facing the workers’ compensation system.