Independent Medical Reviewer Loophole?

By CMTA Staff

Capitol Update, May 27, 2005 Share this on FacebookTweet thisEmail this to a friend

Efforts to reform the worker’s compensation system and achieve cost savings is an ongoing process.  One issue that could be litigated relates to the ability of injured workers to get treatment by doctors outside the Medical Provider Network (MPN).  This depends on how the WCAB and Appeals Courts could define the term "disputed treatment" found in Labor Code Section 4616.4.

The California Division of Workers’ Compensation has finalized regulations that outline the process by which an employee can appeal the medical decisions made by the providers within an MPN.  According to SB 899, (last year’s legislation) a worker employee can appeal a decision by getting three other opinions from within the MPN.  If after that the worker still feels aggrieved, they are entitled to an in-person examination or records review by an Independent Medical Reviewer (IMR) under contract with the Administrative Director of the Div. of Workers’ Comp. 

If the IMR disagrees with the doctors within the MPN, the worker is allowed to obtain the disputed treatment with a physician of their choice within or outside of the MPN. 

The issue at hand is language in Labor Code Section 4616.4 which states that the "disputed treatment" can be obtained outside of the MPN.  The regulations state that treatment outside of the MPN is "limited to the treatment recommended by the IMR or the diagnostic service recommended by the IMR."

In practice the following scenario could arise:  A worker with a back injury disputes the finding of all MPN physicians that he needs no more physical therapy and that his condition is "permanent and stationary."  Upon appeal the IMR finds that the worker is not "permanent and stationary" but needs another 24 sessions of physical therapy, the subject of the dispute.  However, the IMR further finds that the worker needs medications, injections if pain persists, and potentially surgery.  Is the employee entitled to just the physical therapy outside of the MPN?  Or, is the employee also entitled to medications, injections and surgery outside of the MPN under a broader interpretation?

The ability to contain costs and ensure appropriate treatment for workers could be compromised with an expansive interpretation of the ability of workers to go outside the MPN for diagnosis and treatment. Policymakers and employers must remain vigilant to ensure that the intent of worker’s compensation reform legislation is achieved in practice.

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