Utilization Review and IMR (independent Medical Review) is the insurance company’s way to restrict medical care for injured workers to keep their costs down and more money in the insurance company pockets.
Undoubtedly, Utilization Review and IMR (Independent Medical Review) is one way to keep the Workers Compensation low and restricted to the injured workers; on the other hand it saves much compensation money of the insurers and the employer.
You may have got the question by now that what is Utilization Review and IMR and how these two can be used to restrict the compensation for the injured? To know in detail about it, do read the full blog.
What is Utilization Review?
Utilization Review (UR) is a Claims program that the administrators use to ensure that the treatment that the injured worker receives is medically necessary. All the Claims Administrators must and should have the law to process the Utilization Review (UR) program.
This Program lets the administrator decide whether or not to take the treatment recommended by the doctors. At the same time, there are specific Utilization Review (UR) protocols set by the state that should be followed.
If you think that the Utilization Review (UR) Company who is reviewing your request for Doctor’s Treatment is not following all the rules, then you can file a claim with the help of PSLaw Workers Comp.
What is IMR (Independent Medical Review)?
California’s Worker Comp Systems uses IMR (Independent Medical Review) to resolve the disputes involved in Employee injury and subsequent medical treatment. To resolve all the disputes that are increasing in Worker Compensation Claims, this IMR (Independent Medical Review) came into action.
IMR (Independent Medical Review) is an efficient process in which all the injury dates are resolved by physicians assigned by the System through an efficient process called IMR (Independent Medical Review). It is the replacement of a cumbersome and costly court system.
If the Utilization Review (UR) that is claimed by the administrator is unsatisfactory, then the recourse that the administrator takes is known as IMR (Independent Medical Review.) But California’s Workers Comp rules limit the ability to pursue IMR, mostly it is left behind for the patients.
Utilization Review (UR) Process
Before the injured employee gets the desired treatment, it should be made clear to the treating Physician that they receive authorization from the Utilization Review (UR). To request this authorization, the Doctor needs to complete a procedure. It is a normal very long and tedious form that includes several pages and supporting documentation.
After the concerned Doctor fills it off, the physicist has to forward it to the employer’s Utilization Review (UR) company. While in the meantime, the Physician and the injured employee has to wait for the response.
This is the same process for every treatment. It is an arduous process that includes acceptance for every single prescription, x-ray, injection, blood test, diagnosis, splint, and even surgery.
Suppose the Physician fails in providing the mandatory authorization, then the payment that is due, will not be provided to the injured employee.
While there are certain exceptions for emergency cases, here, the Physician should receive the authorization immediately after providing the emergency care.
However, here also the care depends upon the denial of the employer for Utilization Review (UR). Here, the employer owes no money to the employee even though the employee needs urgent care.
This is a way that benefits the insurers or the employer as this saves a certain amount of compensation.
When Utilization Review and IMR (independent Medical Review) Procedure gets accepted
The employee must provide a notice in writing if Utilization Review (UR) has accepted the request for the treatment.
The approval decision should not just be taken by the Physician, it also involves the approval of the injured person and his/ her attorney.
The Communication or the discussion about this should happen within 24nhours by fax, phone, or email. If the Communication took place through the phone, then there should be a written notice about the Communication within 24 hours of the initial Communication.
If the UR approves the Treatment request, then the employer is bound to provide for the required care.
When Utilization Review and IMR (independent Medical Review) Procedure gets Modified/denied/delayed
If a physician is reviewing the Utilization Review and IMR (independent Medical Review) and finds that some of the treatment enlisted is not mandatory for the medical condition, then the Physician ultimately modifies the treatment request according to the requirement.
A Request can be delayed sometimes if specific external evidence is required. In this type of situation, the reviewing physician says about the lack of information that leads to a final decision concerning the initial request.
A treatment request can be denied if the treatment is not authorized.
All these decisions that are taken should be communicated with the requested Doctor, injured employee, and his/ her attorney, within 24 hours of the reviewing result.
The Communication will be enlisted as defective if the Utilization Review and IMR (independent Medical Review) decision is not intact, and proper procedure is not followed.
The most important reason for a modified, delayed, or denied request is the lack of communication, which must be effective.
The decision of denial can also be not made based on a lack of information.
What should an Employee do if Utilization Review and IMR (independent Medical Review) denies or modifies Required Treatment?
If the injured employee is denied from providing the necessary treatment, then he or she, with the help of a Workers Comp Attorney, can file an “Appeal for the denial of Workers Comp Benefits.”
Usually, a UR denial is valid for Twelve Months. If the same request is submitted once again, that means the request contains new elements to consider, or it has already been 12 months.
An Appeal for Utilization Review (UR) is known as IMR (Independent Medical Review). Usually, IMR doesn’t apply to UR decisions that are taken late. The Utilization Review (UR) decisions are invalid if taken late and can’t be used to deny a treatment process.
Each Utilization Review (UR) process that is under modification, denial, or delay has to go through the application of IMR (Independent Medical Review).
The Injured Worker must submit the IMR (Independent Medical Review) request in 30 days of Utilization Review (UR) decision. The Physician has a 30 days time period to review and provide a decision.
As said in the beginning, undoubtedly Utilization Review and IMR (Independent Medical Review) are one of the best ways that insurers incorporate to reduce the Compensation amount. Well, on the other hand, it makes the whole process even tough and time consuming. You are injured, and waiting for the proper treatment is the toughest thing.
To make it easy for you, it is better to consult a workers comp attorney who is best in handling these types of situations. PSLaw is the best law firm in California. PSLaw works only for workers and their benefits.
If you are looking for some expert help, then don’t forget to contact PSLaw today.
We are present in all the major cites in the State of California. You can visit our offices in Riverside, Corona, Hemet, Moreno Valley, Temecula, Palm Springs. We are here, with a group expert Attorney’s who will help you in every way.