Independent Medical Review

Have you been denied medical evaluations, diagnostics and treatment through the California workers' compensation system? Is this a violation of the California Constitution? What is going on with workers' compensation in California? Fortunately, the Law Office of Scott A. Schwartz has been able to navigate and effectively represent its clients; but, most honest attorneys on either side of the fence will tell you that this the worst set of laws applied to the workers' compensation system since its inception. Again, what is going on with California workers' compensation and why is the simplest of treatment more difficult to obtain than one might ever imagine?

Here's a short answer: once a physician makes a Request for Authorization, the workers' compensation claims examiner is meant to send said request to Utilization Review (commonly referred to as "UR").  At that point and depending on the specific request, the claims examiner has approximately ten days to notify you as to whether your physician's request for authorization has been approved.  Accepted treatment is indicated in a fashion in other than plain English or Spanish but is decipherable after a couple reads (depending on your pain levels and medication level insofar as that has been approved).  

Alternatively, your physician's Request for Authorization will most probably be denied and you will be provided with paperwork and an explanation that addresses how to appeal the issue to Independent Medical Review (sometimes referred to as "IMR" and further discussed and defined herein below).  The Law Office of Scott A. Schwartz asks its clients for permission to submit an appeal on your behalf; after all, isn't that why you hired us as your workers' compensation attorney?  More importantly, we skillfully analyze the basis of denial with respect to timeliness or request for additional documents and make sure that the Independent Medical Review (IMR) receives everything they need to make a favorable decision on your behalf. What if that isn't enough to get you medical treatment?

Has IMR simply stonewalled you despite your best efforts? Have four physicians told you that surgery is necessary but it won't get approved by IMR. On occasion, the Law Office of Scott A. Schwartz has participated in meaningful conversation with defense that has resulted in an override of the denial at the utilization review level and authorization of the requested treatment. We have also fought denial of medical treatment in courts and prevailed; however, the system is stacked against the injured worker worse than ever (which makes it all the more important to retain a law office with an understanding of the process and avenues to obtain treatment and work towards recovery after a work injury).

Clients often contact me confused, asking whether it's common that the workers' compensation system deny, deny and deny even the most simplest of test. I tell my clients the honest truth -- the only "medical" test you will receive without scrutiny by the insurance company is a drug and alcohol test in an attempt to swipe you under the rug as intoxicated at the time of accident. Are you annoyed? Can you believe that our elected representatives have implemented a benefit delivery system to injured workers through Senate Bill 863 that does everything but deliver?  Are you mad? You're not alone...and, I am proud that my practice has managed to obtain proper care for many of our clients but it hasn't been without a fight; and, this fight should not be taking place in the first instance. Workers' compensation in California is meant to serve as a benefits delivery system that quickly returns injured workers back to work. What happened is the insurance carriers, who have always been greedy, decided to get a little greedier with you -- even if it means you will never walk the same, again. 

It's time to fight this senselessness...and, the war has begun! See the California Court of Appeal First Appellate District, Division One, which granted the petition for writ of review in Frances Stevens, Petitioner v. WCAB and Outspoken Enterprises/State Compensation Insurance Fund. Our hope that the Court of Appeal gets it right; if not, injured workers should not stand idly...reach out to competent workers' compensation attorneys and explain your predicament. Feel free to contact me with your impasse and, perhaps, together, we can bring justice back to the California workers' compensation system.

How did this wretched turn of events to the California workers' compensation happen? In 2013, the passage of SB 863 allowed for an anonymous supposed physician (i.e., identity of "physician" not disclosed) somewhere supposedly in the United States, who is paid by a workers' compensation insurance carrier, to decide whether an injured worker is entitled to, among other things, an evaluation, diagnostic test or medical procedure. The foregoing is called Independent Medical Review ("IMR" aka "Insurers Maim Recipients" aka "Insurance Murder Recipients" aka "Idiots Making Rules").

Approximately 20% of the IMR requests are accepted (or, overturned from utilization review denials) through the California workers' compensation system and, surprisingly, roughly 80% of medical requests are accepted for individuals with a PPO. The effect is that injured workers are unconstitutionally denied medical treatment and suffer at the mercy of the insurance company. When the dust settles, such individuals are sometimes driven out of the job market due to their ongoing and untreated disability, and often become medicare recipients. Other times, individuals willing and able to work but for a simple curable injury cannot participate in the workforce because the folks behind the IMR scheme mindlessly fire off denials.

Workers' compensation insurance carriers don't care because they don't put up money for medicare -- YOU DO! How could this be constitutional? Well, the nice folks who put together IMR wondered the same thing and are too busy counting their money to be embarrassed as you read this quote: "At the time SB 863 was being negotiated, there were concerns among some proponents regarding the constitutionality of the IMR scheme being proposed. Two memorandums [sic] surfaced, to the consternation of some of the negotiators who were putting the package together," says workcompcentral.com.

Thankfully, the constitutionality of IMR is now before the California Court of Appeal. And, hopefully Frances Stevens, Petitioner, v. WCAB and Outspoken Enterprises/State Compensation Insurance Fund sets us back on a path that respects America's workforce. Otherwise, don't forget to contact me with your difficulties with IMR so that we can destroy the system implemented to deprive us of our rights' under California law.

I invite the voices of those in support of IMR to come forward and explain why I am wrong; it will be hard but please do feel free to comment. In the interim, my goal and intent is to help those who have been victimized by IMR...it's just a skewed system that takes the delivery of medical benefits away from the injured workers who build our society by anonymous individuals out there -- somewhere.

I may be reached at:

NoMoreIMR@scottaschwartzlaw.com or just contact me directly through my website.

The opinions expressed herein are those of the author: Scott A. Schwartz, Esq.

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