UR and IMR Decisions: A Sixty-Second Seminar in Workers’ Compensation Claims Handling

Under California law, utilization review (UR) is designed to address requests for medical services as submitted by primary treating physicians on RFA forms. For the most part UR either certifies or non-certifies requested services, although at times a response may legally be delayed pending receipt of additional information.

When an RFA is certified the requested services are to be provided forthwith. However, when services are non-certified a variety of consequences may occur. The first and foremost consequence is for the injured worker or applicant attorney to file an Application for Independent Medical Review (IMR). Statistics tell us approximately 90% of all IMR appeals are unsuccessful, resulting in a finding upholding UR non-certification. All non-certification decisions issued by UR and IMR are explained in the body of the decision. Unfortunately, most parties, including claims adjusters, seldom read the explanation. Instead, they focus solely on whether the requested services were certified or not, without bothering to read any further. Therefore, the next time a physician or injured worker complains about a UR or IMR decision, refer them to the explanation page.

It is important to note that approximately 10% of IMR appeals are successful. What a claims administrator does upon receipt of an adverse IMR decision is a rather interesting phenomenon to study. In those rare occasions when IMR overturns UR, it usually means that UR committed an error. We surmise that UR would appreciate being informed of an adverse IMR decision as it provides a wonderful learning opportunity by explaining what UR did wrong. By comparison, if management blamed you for making a mistake, wouldn’t you want to know about it, learn from it, and prevent repeating the same error again? Yet, when IMR overturns a UR decision most claims administrators never bother to inform UR. Thus, UR is deprived of an opportunity to learn from its mistakes, resulting in the same mistake occurring over and over again. In fact, we know of one major insurance company who flat out refuses to send adverse IMR decisions to UR because management fears it may be perceived as criticism. More importantly, this insurance company will never admit making a mistake, especially when clients are monitoring claims.  They do not wish to give an impression of being less than perfect. Therefore, adverse IMR decisions are never mentioned. Sadly, when a local manager pointed out how UR was being deprived of a golden learning opportunity, he was viciously chastised by home office and bluntly told to shut up, keep quiet, say nothing, and mind his own business. Before you shake your head in disbelief ask yourself, “What does your company do with adverse IMR decisions and are they shared with UR?”