An IMR is an appeal of a denial of medical treatment. A workers compensation attorney can help you decide whether to file an IMR if your medical treatment has been denied.
In workers compensation cases, an IMR is an abbreviation for “independent medical review.” It is a way that an employee can request a review of an insurance company’s decision to deny coverage for medical treatment.
How the IMR Process Works
Whenever an employee is injured at work, his or her medical treatment will typically be covered by the employer’s workers’ compensation insurance. The doctor treating the worker has to request approval through a “utilization review,” to prove that the treatment is medically necessary, before it will be approved. If this request is denied, delay or modified because the utilization review determines that the treatment is not medically necessary, the injured employer can then ask for an independent medical review (IMR) of this decision. The costs of the IMR are paid by the employer.
In a situation where a workers compensation treatment is denied, delayed or modified, the claims administrator is required to send a copy of the utilization review decision letter, as well as an IMR application form. The injured employee (or his or her workers’ compensation attorney) must submit the application and accompanying documentation within 30 days of the decision. The IMR will then be reviewed by an independent service provider, using a team of health care professionals, to determine whether the denial was proper.
During the IMR process, health care professionals that have not previous examined or treated the injured worker decides whether to uphold or overturn the insurance company’s denial, delay or modification of the requested medical treatment. This team has limited access to the employee’s medical records, and therefore may treat the situation as an isolated incident (rather than a broader medical issue).
What Should You Do If You Receive IMR Paperwork?
In most cases, IMR reviews support a denial of benefits. This may be due to the fact that the insurance company is the party who chooses and pays for the review. Once the insurance company has two separate decisions denying the requested treatment, it is very difficult — if not impossible — to overcome the presumption that the treatment is not medically necessary for the injury suffered.
For this reason, if you have received IMR paperwork, contact our office promptly to discuss your options. Our seasoned workers compensation attorneys can assess your utilization review denial, and determine if there is any deficiency with the paperwork or decision. We can also discuss the risks and benefits of filing an IMR in your specific case, and assist you in filing this appeal should you decide to proceed. Because IMRs have very strict deadlines, it is best to contact a workers compensation attorney as soon as possible after receiving an initial treatment denial. Our lawyers have extensive knowledge in the workers compensation field, including filing IMRs. Contact our office today at (800) 435-7542 or info@plblaw.com to schedule a consultation.