Understanding Independent Medical Review (IMR) in the State of California

The Independent Medical Review (IMR) is a critical process used in the workers’ compensation system, allegedly designed to resolve disputes about the medical treatment of injured workers. Instituted by the California Department of Industrial Relations, IMR aims to ensure that treatment decisions are based on accepted medical standards per the AMA guidelines. 

In this article, we’ll explore how IMR operates, its advantages and disadvantages, and the extreme controversies it has sparked among various stakeholders, including injured workers and Santa Ana, CA workers comp attorneys.

Operation of Independent Medical Review

Operation of Independent Medical Review

IMR comes into play when an insurance company denies, delays, or modifies a doctor’s recommended treatment for a work-related injury claiming that the treatment is not medically necessary. When such a dispute arises, the injured worker can apply for an IMR. The process involves a review by a third-party medical professional who is not involved in the care of the injured worker. The reviewer is tasked with evaluating the medical necessity of the disputed treatment based on the medical records submitted and current standards of medical care per the AMA guidelines.

The IMR process is intended to be faster and less costly than traditional litigation, with decisions typically rendered within 30 to 45 days from the receipt of the worker’s application and all necessary documentation. If the IMR determines that the treatment is medically necessary, the decision is binding, and the insurance company must authorize the treatment. However, if the IMR determines that the treatment is not medically necessary, the injured worker is not able to receive that treatment or surgery for 12 months and then they can apply for another IMR. 

Pros of Independent Medical Review:

  • Speed and Efficiency: IMR offers a quicker resolution to disputes about medical treatment than court proceedings, which can be lengthy and burdensome, even if they are not the correct decision.
  • Cost-Effectiveness: It reduces the costs associated with litigation for both the workers’ compensation system and the parties involved.
  • Evidence-Based Decisions: Decisions are based on established medical guidelines, which help ensure that treatments are scientifically justified and not excessively used or outdated. The issue with this is the subjectivity of the IMR doctor.
  • Reduction of Litigation: By providing a definitive resolution of medical disputes, IMR decreases the need for costly and time-consuming court cases.

Cons of Independent Medical Review

  • Lack of Personal Medical Assessment: The IMR process does not involve a physical examination of the injured worker by the reviewer, potentially leading to decisions that may not fully account for the worker’s unique medical situation. This is a huge problem as doctors and work comp lawyers argue that, with no physical examination, no objective educated recommendation can be achieved. 
  • Perceived Bias: Critics argue that the IMR system is biased towards insurance companies, partly because it uses doctors who may not have the same depth of understanding of the patient’s condition as the treating physician. They also argue that IMR doctors are biased, as they stand to lose the excellent money they are making by ruling in favor of the insurance company and getting more IMRs.
  • Limited Recourse for Workers: The binding nature of IMR decisions means workers have limited options if the IMR upholds a denial of treatment. This means that a denied IMR delays possibly extremely necessary medical treatment such as surgeries to prevent further damage and degeneration of injuries. 
  • Complexity and Accessibility: Some workers find the IMR process complex and difficult to navigate, especially those with limited knowledge of medical or legal terminology.
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Controversies and Efforts to Overturn IMR

The IMR system has been controversial among various stakeholders, including injured workers, applicant attorneys, and some medical providers. Many argue that IMR often sides with insurance companies, denying necessary treatments based on rigid interpretations of medical guidelines that do not consider individual patient needs. This has led to significant frustration among injured workers who feel their recovery is hindered by denied treatments.

Applicant attorneys and workers’ rights groups have raised concerns about the transparency and fairness of the IMR process. They contend that the system is opaque and that decisions are made by reviewers who may lack the appropriate specialties to fully understand complex medical issues.

Efforts to challenge or reform IMR have been ongoing. Legal actions have been mounted against the constitutionality of IMR, arguing that it deprives workers of their right to a fair trial and due process. For instance, in 2017 and again in 2020, California courts upheld the constitutionality of IMR, but these decisions have not deterred continued advocacy for change.

Doctors and workers’ compensation lawyers have also been active in calling for legislative reforms that would improve the transparency and fairness of the IMR process. These efforts include:

  • Proposals to ensure that medical reviewers are matched more closely with the specialty relevant to the treatment in question
  • Initiatives to allow for an easier review of IMR decisions, including an appeal process to IMR. 

As of now, IMR is the final judgment and there are no mechanisms to challenge the decision, which is where the argument for the right to due process being denied to the injured worker originates from.

Summary & Future Considerations

While the Independent Medical Review (IMR) system in California offers a mechanism designed to streamline the resolution of disputes over the medical treatment of injured workers in the State of California, it is not without its glaring flaws and controversies.

The system’s aims to reduce litigation and ensure evidence-based medical decisions are commendable, yet its execution often leaves injured workers and their advocates dissatisfied and seeking reform, due to not allowing any appeal for a full calendar year to the day.

As such, the debate over IMR continues, reflecting broader tensions within the state’s workers’ compensation system regarding the balance between efficiency, fairness, and the well-being of injured workers. 

Additionally, workers comp lawyers and doctors contend that the IMR process is not more cost-effective and is costing the system more in the end by denying necessary treatment due to the IMR medical professional having limited information, most importantly not conducting a physical exam, 

Where in Santa Ana, CA can I find specialist workers comp attorneys near me?

California Workers’ Compensation Lawyers, APC is a collection of experienced and highly specialized legal professionals, with a long and impressive track record of excellence. So far, our joint efforts resulted in more than $1 billion recovered in benefits, to the ultimate satisfaction of our clients. Whether you wish to know more about the inner workings of the CA Work Comp system, have specific questions about applying SIBTF in OC, or need a dedicated team to represent you in the court of law, our locally-based firm offers many benefits that go beyond mere advice. Get in touch with us today to schedule your FREE consultation at our offices near Saddleback View Park and secure a partnership that will put your interests first.