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California Division of Workers’ Compensation Posts Adjustment to Official Medical Fee Schedule (Pathology and Clinical Laboratory Section)

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July 1, 2020
California Insurance Commissioner Ricardo Lara launches “Invest in Our Diverse Communities” Initiative to increase insurance investment in socially responsible projects; announces major appointments to COIN Advisory Board

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The California Department of Industrial Relations (DIR) and its Division of Workers’ Compensation (DWC) have posted a progress report on the Department’s Independent Medical Review (IMR) program. IMR is the medical dispute resolution process for the state’s workers’ compensation system that uses medical expertise to obtain consistent, evidence-based decisions.

The report describes IMR program activity in 2018, the sixth year since the program was implemented. The Independent Medical Review Organization administering the program, Maximus Federal Services, Inc., received over 250,000 IMR applications, and issued almost 185,000 Final Determination Letters, each containing one or more medical necessity disputes.

Highlights of the report:

• The monthly average length of time to issue an IMR determination after receipt of all medical records had decreased to nine days toward the end of 2018.
   
• An average of 15,400 IMR decisions were issued each month.
   
• The number of eligible applications increased for the sixth consecutive year.
  
  
• Case decisions continued to be similar when comparing several demographic categories, including injured workers’ date of injury, their representation status, and the geographic region of their residence.
  
  
• Treatment request denials were overturned at a rate of 10.33 percent, with specialist consultations, office visits and mental health services overturned most often.
   
• More than 40 percent of treatment requests sent for IMR were for pharmaceuticals, with opioids comprising nearly one of every three pharmaceutical requests.
  
  
• Guidelines contained in the Medical Treatment Utilization Schedule continue to be the primary resource for the determination of medical necessity.

 The progress report is posted on the DIR website.

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lonce@adjustercom.com, Lonce Lamonte, journalist and editor, with the DWC Newsline release of November 15th 2019