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California CWCI Independent Medical Reviews – Other Statistics


California CWCI Publishes Quarterly Report on IMR Statistics – The Other Numbers

The California CWCI (California Workers Compensation Institute) recently published a spotlight report on the state’s Independent Medical Review (IMR) process.   The IMR process was initiated due to Senate Bill 863.

Map California CWCI Stars Bear

If a UR (utilization review) physician provides an opinion which denies the medical treatment, the injured employee has the right to dispute that finding.

If the injured employee decides to dispute the decision of the UR physician, the IMR process provides an avenue to have an independent physician review the denial of services.   The IMR physician can overturn or uphold the decision.

The main statistics that created a buzz in the Workers Comp blogosphere are:

  • 90% of all denials were upheld
  • 160,000 review letters
  • 1/2 of the reviews were for medications (40% of the medication reviews were for opioids)

As they say in Monty Python(c), now for something completely different:

  • Over 20% of psychological  services denials were overturned by the IMR physician
  • Almost 30% of the “evaluation and management” services denials were overturned by the IMR physician

Both of these two service categories did not make up a large amount of the IMR reviews.   However, the percentage of overturned denials was remarkable.

Woman Doctor California CWCI Holding Folder

One area from the medication IMR statistics by CWCI was antidepressants.  The IMR physicians had overturned almost 30% of the antidepressant denials.  Even though antidepressants accounted for only 4% of the reviews, this was a striking number.

The most interesting statistic, in my opinion that came from the CWCI study was that the top 10% of medical providers that were mentioned in the IMR letters accounted for 75% of the reviews.   

Will California’s Department of Workers Comp look more into that statistic?   We shall see.

The study can be found here.

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James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


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