Independent Medical Review
An Independent Medical Review (IMR) is a process to resolve disputes around medical treatment during the workers’ compensation process. Following a work-related injury, your primary treating physician will request approval for medical treatment to treat your injury by way of a Utilization Review. However, the claims adjuster often denies or modifies the treatment due to the treatment not being considered medically necessary. You are able to appeal the decision by requesting an Independent Medical Review. An independent medical specialist will review your medical history and other documents relevant to your condition, but they will not physically examine you. The Independent Medical Review decision becomes the final decision in regards to the medical care requested. An experienced Stockton workers’ compensation attorney can help you understand the entire Independent Medical Review process. Contact Stockton Workers’ Compensation Attorneys, P.C., if you have any questions regarding an Independent Medical Review, and we will assist you.
What takes place during an Independent Medical Review?
The California Department of Insurance hires a for-profit company called Maximus Federal Inc. to select independent medical experts. The examining physician never visits you in person or speaks with you about your condition. You do not have the right to consult with them or to speak freely about the symptoms. Instead, they write a report that you, the insurance provider, and the insurance commissioner get. The California Department of Insurance receives a final report from the insurance commissioner.
The decision issued during the Independent Medical Review is binding. If it is determined that the denied treatment was medically necessary, the workers’ compensation claims administrator must immediately comply with the decision and authorize treatment within five days. If the Independent Medical Review determined that the denied treatment was medically necessary and your physician already provided the treatment, the workers’ compensation claims administrator would have 20 days to reimburse the medical provider for the treatment.
How do you apply for an Independent Medical Review?
You must first complete a Utilization Review and be refused treatment for your workers’ compensation accident before requesting an Independent Medical Review. You have 30 days from receiving the Utilization Review denial to request an Independent Medical Review. Within those 30 days, you must submit the “Application For Independent Medical Review” form and submit a copy of your Utilization Review decision letter. You may lose your right to appeal for at least one year if the appeal is not filed within the 30 days required.
Who requests an Independent Medical Review?
The injured employee or an appointed representative such as an attorney, parent, guardian, conservator, relative, friend, or physician can request an Independent Medical Review. You are able to request an Independent Medical Review for a workers’ compensation claim if your claim for a medically required and routinely covered procedure was postponed or refused. If your claim for emergency treatment was denied, then you can request an Independent Medical Review. Lastly, if you were rejected investigational or experimental treatments, you can request an Independent Medical Review.
An Independent Medical Review is not available for workers’ compensation claims if you submitted your Independent Medical Review application late or if the claim’s liability is still up for debate. In addition, if the insurance policy does not cover the care, then the claim is not eligible for an Independent Medical Evaluation.
What can Stockton Workers’ Compensation Attorneys, P.C. do?
If you are refused care after engaging in an Independent Medical Review, you still have options. Our lawyers will help you understand what happens during an Independent Medical Review, who can request one, how to request one, and whether or not your application is qualified for one. Contact a workers compensation attorney at Stockton Workers’ Compensation Attorneys, P.C., if you have questions about how an Independent Medical Review will impact your workers’ compensation case.