California’s SB 863 created a new process for dispute resolution in connection with the utilization review (UR) process. After the standard UR process has run its course and an adverse determination has been rendered, an injured worker can request an Independent Medical Review (IMR). The IMR is a mechanism to remove disputes over medical necessity from judges and put them in the hands of doctors. Not a bad idea.
The vendor for IMR services is Maximus Federal Services. As reported in a workcompcentral article, the company recently sent a recruitment letter to California doctors offering $150 per case for standard reviews and $200 per case for expedited reviews. At least one doctor, a cardiologist in Southern California by the name of Paul Grodan, thinks those rates are “ridiculous.” But not just “ridiculous”… he shared some other choice words with author Greg Jones:
Reports for which doctors were paid those rates “would be worth toilet paper.”
“I can’t even get a plumber to my house for that.”
And my personal favorite: “It’s tantamount to having a death penalty case and paying the death penalty lawyer $150 for the appeal.”
(Leaving aside for a moment that the vast majority of death row inmates don’t even have legal counsel and among those that do, most of the work is done pro bono…)
Clearly, Dr. Grodan has taken the offer as a personal affront. But such hyperbole has no place in the discussion on how best to deal with the dispute resolution process and how to make the IMR process work. While acknowledging that a flat-fee arrangement might work under certain conditions, Dr. Grodan predicts the imminent failure of the IMR concept as currently contemplated.
Here’s the reality of work comp UR: it is much more process-oriented than Dr. Grodan thinks. The typical UR case constitutes a request for a medical test, procedure, or therapy. The request is compared to evidence-based guidelines. There’s a match… or there’s not. A decision is rendered. Are there cases that end up in a gray area? Of course. But those cases require more professional judgment than painstaking review of thousands of pages of medical records.
Mr. Jones should have interviewed more than one doctor. Dr. Grodan should have chosen his words a bit more judiciously. If we step back, consider multiple view points, and remove the hyperbole, we’re likely to find a tenable solution to this simple economic issue.
On Twitter @PRIUM1
On Twitter @PRIUM1