What Is an Independent Medical Review (IMR)?
If you've ever pursued a workers' compensation claim, you may have heard the term "Independent Medical Review," or IMR. It's a critical part of California's workers' compensation system, providing a valuable alternative to court disputes for injured employees. But what exactly is it? How does it work? And who's eligible to request one?
At The Law Office of Robert E. Wood, our workers' comp attorney is well-versed in the intricacies of IMR and is here to help you understand how it can benefit your case. If you're seeking legal assistance in the San Francisco Bay Area, contact our office in Oakland, California, to set up a free consultation.
Understanding Independent Medical Reviews
So, what exactly is an Independent Medical Review? Simply put, it's a process that allows injured workers to dispute medical treatment decisions made by their employer's insurance company.
An IMR involves a review by physicians who are independent of both the claims administrator and the treating physician of the injured worker. The goal? To determine whether the requested medical treatment is medically necessary and should be approved.
The decision made by the Independent Medical Reviewer is binding and cannot be appealed. This means that if the IMR finds in favor of the injured worker, the treatment must be provided by the employer's insurance company. Ultimately, this process offers a cost-effective and streamlined way to resolve disputes, with employers shouldering the costs, not you.
Who Can Request an IMR?
If you're an injured worker and your treating physician's request for medical treatment has been denied, delayed, or modified after the insurance company's utilization review (UR) process, you have the right to request an IMR.
This gives you the chance to challenge the UR decision and seek an independent review. Remember, our attorney is here to stand by your side throughout this process, advocating for your rights every step of the way.
When Can an IMR Be Requested?
Since July 1, 2013, all dates of injury are eligible for IMR. If you receive a UR determination, it's essential to submit the IMR application form within 30 days. Time is of the essence in these situations, so acting promptly can help you achieve a timely resolution of the dispute.
What Issues Are Eligible for an IMR?
IMR can be requested for disputes related to the medical treatment of work-related injuries and illnesses. The focus is on determining the medical necessity of the requested treatment. It's all about ensuring that you, the injured worker, receive appropriate and necessary medical care.
What Issues Are Not Eligible for an IMR?
IMR isn't a catch-all solution. There are certain issues, such as disputes related to liability, that are not eligible for an IMR. However, once the liability issue has been resolved, IMR becomes available.
Also, keep in mind that for claims under investigation or where liability has not been denied, IMR is available within the first 90 days after the claim is presented for medical treatment costs up to $10,000. Our workers' comp attorney can help you understand the full scope of what is and isn't eligible for IMR.
IMR Process
To get the ball rolling with an IMR, you, or your representative must submit a request to the claims administrator. This request should include the completed IMR application form (DWC IMR-1 form) and a copy of the utilization review determination provided by the claims administrator.
The responsibility of providing the required medical records to the IMRO within the specified timeframes falls upon the claims administrator. They also have to notify you or your representative of the documents submitted to the independent medical review organization (IMRO).
Once the Administrative Director determines that your dispute is eligible for IMR, Maximus, the organization tasked with conducting IMR, sends out a Notice of Assignment and Request for Information (NOARFI) to all parties involved. This notice will indicate whether the review will be regular or expedited.
For regular reviews, the claims administrator must provide the required medical records to Maximus within 15 calendar days of the designated date. For expedited reviews, they have a tighter timeframe — the required medical records must be provided within 24 hours of receiving the notification.
If you have any questions or concerns about the IMR process, feel free to reach out to us at The Law Office of Robert E. Wood.
Keys to a Successful IMR
To improve the chances of a successful IMR, there are certain steps to follow. These include:
Providing the correct IMR application form,
Clearly indicating the type of review (regular or expedited), and
Including the WCIS number.
The WCIS, or Workers' Compensation Information System, is an essential component in the IMR process. It's a comprehensive database that collects and manages workers' compensation data from insurers, self-insured employers, and third-party administrators. The WCIS number, which is unique to every claim, is crucial for a successful IMR application as it helps in the identification, tracking, and management of the case.
Adhering to these guidelines and submitting the IMR application within the specified timeframes can be crucial for success.
Get the Support You Need
At The Law Office of Robert E. Wood, we believe that every injured worker has the right to receive proper medical treatment after a workplace injury. We also understand that navigating the California workers' compensation system can be complex and overwhelming. That's why we're here to guide you through each step of your case, including the IMR process if necessary. Contact our firm today in Oakland, California, to schedule a free consultation and learn more about how our attorney can help with your workers' compensation claim.