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The California workers’ compensation system’s independent medical review (IMR) process, which is used to resolve medical disputes, climbed by 6.5 percent in 2016, a new report shows. This is despite the fact that last year, physicians once again upheld about 90 percent of treatment denials. The California Workers’ Compensation Institute’s analysis is based on a review of data from 477,045 IMR decision letters issued in 2014, 2015 and 2016 in response to applications submitted to the state after a physician modified or denied a requested medical service.

 

An article in the Insurance Journal says state lawmakers who included IMR in the 2012 workers’ compensation reforms expected the process would reduce workers’ compensation treatment disputes once doctors, attorneys and other participants came to understand which services would be approved because they meet evidence-based medicine standards. Three years into those reforms, however, the IMR volume is at a record high. The Division of Workers’ Compensation reports that there were 10,477 more cases in 2016 compared to the previous year. The 2016 IMR outcomes data show that physicians upheld the denials 91.2 percent of the time, also up from 88.4 percent in 2015.

 

What is an Independent Medical Review or IMR?

 

California’s workers’ compensation system uses a process known as independent medical review (IMR) to resolve disputes about injured employees’ medical treatment. Starting on July 1, 2013, disputes with regard to medical treatment were to be resolved by physicians through the IMR process rather than the court system.

 

A request for medical treatment in the workers’ compensation system is required to go through a “utilization review” process to confirm that it is medically necessary before it is approved. It utilization review denies, delays or modifies a treating physician’s request for medical treatment because the treatment is not medically necessary, the injured worker can ask for a review of that decision through IMR.

 

Employers are required to pay the costs of the IMR. The costs of IMR are based on the nature of the medical treatment dispute and the number of medical professionals who are needed to resolve the dispute. They could cost between $123 and $515 per IMR.

 

Handling Your Independent Medical Exam

 

If there is a dispute regarding your medical condition in your workers’ compensation case, the insurance company may ask you to undergo an independent medical examination or IME by a doctor of its choosing. This is basically a medical evaluation to resolve questions about your medical condition including what treatment is necessary and the degree of your permanent impairment. An IME is usually requested by the insurance company where a question arises about the type of treatment you need to recover or the permanent disability rating you should be given. Sometimes, a judge may order an IME to resolve a disputed issue related to your workers’ comp case. An IME can have a profound impact on your case because IME doctors are viewed as experts and their reports will be given weightage by workers’ compensation judges and hearing officers. These doctors are also seen as more objective because they are not involved in your treatment. Therefore, they have more credibility.

 

First, it is important that you are familiar with your medical history. The doctor will look at all of your medical records including those involving prior injuries to the same part of the body. Be ready to review the details of the accident including precisely how the injury occurred. The examiner will do this to make sure that your injury is work-related. Be familiar with the type of treatment you received. The examiner will also ask you about your treatment history for the injury.

 

Review your current symptoms including any pain you are experiencing and your limitations. As you prepare for the exam, be sure to dress appropriately. For example, if you have suffered a leg injury, you probably shouldn’t come to your exam in high heels. Plan to arrive early because you may lose your benefits if you miss your appointment time. Bring a friend with you who can take down notes or provide emotional support during the exam, while serving as a witness.

 

Tips for a Successful Exam

 

Here are some of the things you can do to ensure that your independent medical exam is successful:

 

  • Be honest and consistent. Most of these examiners are truly experts in their field. So, they have ways of determining if people are accurately reporting their symptoms. If you are caught exaggerating your symptoms, you may lose your credibility and it may become a major challenge for you to receive the benefits you rightfully deserve.
  • Be calm and polite. It is important that you remain respectful to the examiner at all times. Remember at all times that responding in a rude or hostile manner could work against you. Don’t assume that the examiner is out to get you. Even if he or she does not appear friendly, it would be in your best interest to remain polite.
  • Be honest about what you can and can’t do. While you shouldn’t exaggerate your symptoms, you should not understate your limitations either.
  • If you have suffered a previous injury to the same body part, explain how the new injury is different. Make sure that you properly distinguish your prior injury from the current one.

 

If You Have Been Injured

 

If you have suffered injuries in a work-related accident, it is important that you take a few steps to ensure that your legal rights and best interests are protected. First, make sure to report the incident to your employer and/or supervisor as soon as possible. Get prompt medical attention, treatment and care for your injuries. Preserve all documents relating to your doctor office visits, hospitalization and treatments including physical therapy sessions. Preserve as much evidence as possible from the scene. Obtain contact information for anyone who may have witnessed the incident. Contact an experienced Glendale workers’ compensation lawyer who will fight for your rights and help ensure that you receive maximum support for your injuries, damages and losses.

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