Review shows 4.1% increase in first half of 2023, mostly in therapy, injections, prosthetics
In its review of the Independent Medical Review (IMR) process that resolves California worker’s compensation disputes, the California Workers’ Compensation Institute (CWCI) found that after the lowest high on record in 2022, numbers are back on the rise.
The CWCI reviewed more than 1.3 million IMR decision letters ranging from 2015 through June 2023, a press release stated. The letters are issued to the state after a Utilization Review (UR) physician denies or modifies a worker’s comp request.
Data reveals a downturn of disputes during the pandemic due to reduced work injury claims and a reduction in pharmaceutical disputes. Disputes reached a record high of 184,735 in 2018, then declined 31.1% for the next four years.
The pharmaceutical reduction was largely due to the adoption of the Medical Treatment Utilization Schedule (MTUS) Prescription Drug Formulary in 2018, and the Pain Management and Opioid Guidelines in 2017, said the CWCI.
The pharmaceutical change had the biggest impact, with the number of prescription drug disputes falling from 47.3% of all IMRs in 2017 to 33.3% in 2022. That trend continues this year, with data showing prescription drug disputes making up 32.6% of all disputes up to June.
Opioid claims have dropped from a third of pharmaceutical IMR claims in 2018, to less than a quarter as of this June.
Since 2018, IMR disputes related to physical therapy, injections, and durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) have had the most significant increases, said the CWCI.
Physical therapy disputes around workers’ compensation have jumped from 10.3% to 13.4%, injection disputes from 9.0% to 12.1%, and DMEPOS rose from 7.1% to 8.9%
Only 1% of reporting physicians account for a disproportionate number of IMR requests from June 2022 to June 2023, according to the press release. This means 80 doctors submitted 40.3% of all dispute claims submitted for review.
The CWCI report states that this statistic is in line with previous CWCI reviews, and notes that 9 out of 10 of the highest reporting doctors for this period were also on the top ten list the previous year.
“Uphold” rates (the number of physician recommendations upheld by IWL doctors) remained stable, the report said, with acupuncture, at 92.9%, having the highest uphold rate.
The number of total disputes remains lower than pre-pandemic rates.
The CWCI is a private non-profit organization of California insurers that collects and analyses claims data.
