The NBC team in the Bay Area, California, has been working on a report of the California workers’ compensation system. They released their findings of the state’s independent medical review process and found that in the vast majority of cases, denials of appeals are not overturned.

If an injured worker wanted to appeal the denial of their medical treatment they used to go before a judge. After California’s work comp reforms went into effect, workers now go through independent medical review where doctors look at their case. They found that almost 90 percent of the time, the reviewer upholds a denial of medical care that an injured worker has appealed. These doctors are not chosen by the worker and have not been treating the patient; they use standard medical guidelines to make their decisions. Patients argue that they might not be receiving the best medical care based on their specific case and circumstances.

Research from the California Workers’ Compensation Institute (CWCI) says the reforms are working and that the majority of medical care that patients need does get approved. They found that 85 percent of medical services were paid without needing a request for authorization or undergoing a utilization review, and then of the 15 percent that did go through a RFA and UR, 59.8 percent were then accepted. They too found that IMR doctors upheld denials 89.1 percent of the time, but they attribute that to the UR process doing their job and denying care based on evidence-based medical guidelines. They study did find that half of IMR cases in the first half of 2015 were related to disputes about prescription drugs, 11 percent related to compound drug requests and a third related to opioid requests. The Workers’ Compensation Insurance Rating Bureau (WCRIB) said that the number of appeals in 2014 and 2015 were three times higher than they expected.

The study did find that the top 10 percent of physicians making IMR decisions (961 doctors) were involved in 80 percent of IMR letters, and the top 1 percent of physicians (97 doctors) were involved in 40 percent of IME decisions.

WCRIB reported that medical costs have been decreasing in California and employer premiums are declining, which they largely attribute to the new fee schedule and the IMR process.