IMR ERRORS (California) (California)

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IMR ERRORS (California) (California)

Postby mk61347 on Tue Jun 06, 2017 8:57 am

I have had two cases were the reviewer made an error in the IMR review. Has anyone else had the same experience.

Currently, the process is to take the matter to the local board. I got an atty to do this one time. The matter was set out about two months for an MSC. The ins co atty agreed there was a mistake; however, the adjuster would not authorize services. Therefore, the judge set the matter for a hearing about 6 weeks later. If the judge had found in our favor, all we would have won is for the matter to be returned to IMR for a rereview. I again submitted the matter for UR and this time it was approved so the hearing was cancelled.

I called the IMC . They first told me to send the documents to them as an audit and the medical director would review and send the matter back to Maximus if he agreed there was an error. I did this(even though I knew this was not the process). When I called a week later I was told to take the matter to the local board there was no other process to correct an error from Maximus. I explained the problem of two hearings at the board and the delays which at best only would get a rereview from Maximus and not treatment. They said the medical director was too busy working on drug formulary to do anything to correct the problem.IE an appeal process at maximus when they make an error.

I am wondering how widespread is the problems of IMR errors. Thank you
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Re: IMR ERRORS (California) (California)

Postby LawAdvocate on Tue Jun 06, 2017 9:24 am

Since there is no mechanism to track this statistic, it would rely on anecdotal evidence. Based on my experience, extremely rare
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Re: IMR ERRORS (California) (California)

Postby mk61347 on Tue Jun 06, 2017 9:29 am

That is why I am asking if others have same problem, to start collection of data.
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Re: IMR ERRORS (California) (California)

Postby LawAdvocate on Tue Jun 06, 2017 1:59 pm

That will unfortunately be an other anecdotal study. IN order to have a valid study, you would have to specifically define "error" and then hope that everyone who sees one refers it. Your version of error and my version of error may in fact be two different animals. That is why the DIR and the DWC tend to track this stuff, they define and have access to all of it.
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Re: IMR ERRORS (California) (California)

Postby vampireinthenight on Thu Jun 08, 2017 8:30 am

I find the lack of any meaningful appeal to be offensive. Sorry, probably off topic. I don't know if collecting data on error rates would accomplish much. If there was a high rate of error, what would be the proposed remedy? Replace Maximus?
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Re: IMR ERRORS (California) (California)

Postby LawAdvocate on Thu Jun 08, 2017 2:49 pm

If there was indeed a high error rate, the correction/remedy would be to attempt to identify the source of the errors and change the process contributing to those errors.

An absurd example - but what if every topical compound medication UR non-cert was overridden by Maximus because the MTUS Guideline Pain Mgmt Chapter was deleted from their system? The remedy would be to replace it on the computer system, no?
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Re: IMR ERRORS (California) (California)

Postby Barney5 on Sat Jun 24, 2017 1:39 pm

mk61347, in my opinion there is a HUGE problem with IMR "mistakes". That is a very nice word for what I have seen happen with IMR decisions. Can you be more specific when you wrote mistake? What I have seen is things like a total lack of reviewing records sent, and also the use of guidelines incorrectly. I can appeal MANY UR denials through the UR internal appeals process. I see some "mistakes" happen there too, but not as often. So why am I not able to successfully overturn denials when they are sent to MAXIMUS like I can with internal UR...they use the same guidelines? I believe many of the IMR reviewers are not reading records sent. It is obvious when I sent records that shows why the request was warranted and also addresses the reasons for the original UR denial and I get a regurgitation of the original UR denial.

I also do not know if when I send MAXIMUS a cover letter is actually forwarded to the IMR reviewer, I have yet to find this information out. My cover letters are never listed with the records received in the IMR review and I have been told a middle man at MAXIMUS decides what is sent to MAXIMUS gets forwarded to the IMR doctor. My cover letters laying out patients history, reasons why the request was warranted, medical treatment guidelines and also list where in the stack of records they can find everything.

Mk6147 as you have described the process they have in place when there is a "mistake" with IMR review can be long. Since applicant attorney's do not get paid for taking these issues to court, many do not. What I do when these mistakes happen, which most of the times is failure to review records is I advise the injured worker to kindly ask their doctor to make the request again and check off the box on the RFA under change of material facts. If the IMT physician failed to review the patients records then in my opinion this is new information, and the same goes for UR, if UR physician was not provided with all relevant records or failed to read them this is change of material facts known to the reviewer. This is much quicker than taking issues to court. I only suggest this when it is obvious records were not reviewed by "mistake".

I also recommend as much as you can to use the internal UR appeals process BEFORE IMR as the chances for approval are much higher. I believe this is due to the physician reviewer has to provide his name.

I do not know if you or anyone can answer the question but I will ask it. I have yet to get an answer from MAXIMUS. If a cover letter that addresses the reason why the request was warranted, addresses the UR denial and provides medical treatments guidelines including algorithm that lays out past treatment and condition that matches medical treatment guidelines is sent to MAXIMUS by a non physician, an applicant attorney, IW or patient advocate will the cover letter be forwarded to the IMR reviewer? My cover letters are never listed in the reply from MAXIMUS in their determination letter, just medical records sent and it is clear the reviewer did not read it or I wonder if they were ever sent it.

I agree with you Vampireinthenight, there is a problem with lack of meaningful appeals. I hope with the recent change giving medical providers the ability to charge for record review for UR and IMR appeals this will change. Before this those who did this work could not bill for it.
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Re: IMR ERRORS (California) (California)

Postby lacompfun on Sun Jul 30, 2017 3:48 pm

The issue would be getting enough data for the study... Something the Rand Corporation or State of California might be able to do..
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