Most workers comp medical reviews agree with treating physician


In the first half of 2017, more than 91.3% of all utilization review physicians’ modifications or denials of treatment that were reviewed by an independent medical review doctor in California were upheld, a study released Thursday by the Oakland-based California Workers’ Compensation Institute revealed.

The independent medical review process was established by state lawmakers to resolve medical disputes. California law requires workers comp claims administrators to have a utilization review program to assure that care provided to injured workers is backed by clinical evidence outlined in medical guidelines adopted by the state. 

Most treatment requests are approved by the utilization review, the institute reported, but in 2012 state lawmakers adopted independent medical reviews to give injured workers a chance to get an independent medical opinion on treatment requests that utilization review physicians deny or modify.  

The institute tallied 86,066 independent medical review decision letters issued in the first half of this year in response to applications submitted to the state after a utilization review physician modified or denied a medical service request. 

The institute’s analysis of the decisions made this year found that after reviewing the patient’s records and other information provided to support the request, independent medical review physicians upheld the utilization review doctor’s modification or denial of the service 91.3% of the time — nearly identical to the 91.2% uphold rate in 2016, according to the study. 

As in prior years, pharmaceutical requests accounted for almost half of the 2017 independent medical review decisions. Opioids represented 28.8% of all 2017 prescription drug independent medical review decisions even though doctors have consistently upheld the utilization review decision in 90% of the opioid requests, the study showed.