California WC IMR: 1st Quarter 2015 Outcomes (Spotlight Report, published 07/15)

This study measures the volume of independent medical review (IMR) decisions generated in the 1st quarter of 2015, as well as the number of injured workers, utilization review (UR) events, and medical services associated with those reviews, and the percentage of the medical service requests that were modified or denied by a UR physician that were subsequently upheld by the IMR physician. In addition, the study identifies the month-to-month trends in IMR-eligible applications and determination letters for the 15-month period of January 2014 through March 2015; the number, mix and uphold rates of the 1st quarter 2015 IMR decisions by the type of medical service requested; the percent of all IMR determination letters issued in the 1st quarter of 2015 that were linked to the top 10 percent of high-volume physicians; and the proportion of 1st quarter determination letters and treatment decisions that involved the 10 individual physicians with the highest number of disputed medical service requests. The study also shows the distribution of IMR determinations by region and the areas that had a disproportionately high or low number of treatment disputes relative to their workers’ compensation claim volume.