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CWCI Study: Roughly 85% of UR Upheld by IMR

Hello, dear readers!  It’s a glorious Monday Morning, and your humble blogger has some rather interesting news for you:  it appears that about 85% of UR denials are upheld (and, sometimes, even held up) by IMR.

Insurance Journal reports that CWCI’s study concludes that if you get a UR denial, you are likely to get an IMR affirmation.

Thinking about it in terms of dollars and sense (see what I did there?) if you’re paying your UR, whether the treatment is denied or recommended, and you’re paying your IMR vendor, whether the treatment is denied or recommended, perhaps it’s time to run the numbers again.

What’s the best formula for deciding whether to override a UR denial?

If [cost of IMR] x .85 > cost of treatment, override it!

On the bright side, things like physical therapy, chiropractic visits, and acupuncture are limited, by statute, to 24 (see Labor Code section 4604.5(c)(1)), so even if you override UR, after 24 visits you  might not have to provide the treatment anyway.  But, as the conventional wisdom goes, it might make sense, globally, to pre-authorize certain treatments so that you can even skip out on the UR bill too – odds are that certain injuries are going to require physical therapy or prescription medication, etc., so why suffer the UR bill when you’ll likely have to provide it anyway?

In summary, dear readers, this is pretty good news, at least for now.  As you will recall, IMR was dearly paid for with a lot of momentum to get SB-863 on the Governor’s desk and signed, and the battle still rages in the courts to about its constitutionality.  Although, as you may have heard, the Court of Appeal in Stevens held that IMR, even when late, is constitutional and the California Supreme Court, on February 17, 2016, denied to review it.

What do you think, dear readers?  Is it worth it to send every single RFA to UR and to allow an IMR?  Or would defendants be wise in adopting a measured response?

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