Report: 90% of Workers' Comp Utilization Review Decisions Upheld in California

Posted By Law Offices of Wax & Wax || 23-Feb-2016

A new report this month from the California Workers’ Compensation Institute reveals that nearly 90% of all disputed workers' compensation utilization review decisions are upheld during the independent medical review process. It was also found that a significant portion of the disputed decisions involved prescription medications.

As Insurance Journal reports, CWCI officials believe the findings—culled from 2015 statistics—prove that the relatively new California worker's comp review system is "steady" and "very stable." "It tells us that there is a consistent character in the decisions that are being made by the independent medical review," said Alex Swedlow, president of the CWCI.

Utilization reviews are used to monitor the health of worker's compensation claimants. When these reviews alter or terminate any part of a claimant's treatment, they and their doctor have the option to dispute the decision by applying for an independent medical review by assigned, impartial doctors. Judging by the recent 2015 data, of the 300,000 IMR cases serviced last year, only about 10% were reversed in the workers' favor.

A Focus on Prescriptions

The CWCI has also identified the source and nature of many of the disputed utilization review decisions. According to the findings, a "small circle of doctors" are responsible for a sizable portion of disputes over prescription medications. Swedlow confirmed that nearly 50% of overall disputes concerned prescriptions.

While there is a concern over the high number of prescription medication disputes, many are hopeful about the Assembly Bill 1124. Passed and signed last year, Assembly Bill 1124 will create a statewide drug formulary for workers' comp claims by next year. The formulary will help create standards for medication prescriptions and regulate how long claimants should be on anyone particular drug. "It’s the wish and the hope of the legislative intent in AB 1124 that our state-mandated formulary will help eliminate a large layer of these conflicts," Swedlow told Insurance Journal.

If you are a worker who has been hurt on the job and needs assistance with your workers' compensation claim, we invite you to contact us at the Law Offices of Wax & Wax. Our experienced and award-winning Glendale workers' compensation attorneys understand how sensitive and discerning California's workers' comp system is and have helped countless clients cut through the red tape and recover the relief they deserve.

Don't hesitate to put proven workers' comp advocate by your side for this process. Call 818.946.0608 today to tell us your story.

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