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Transforming the medical appeals process for the California Workers Compensation program

California implemented a cost-effective, non-judicial process Independent Medical Review (IMR) Process developed by MAXIMUS as part of the state’s reform efforts to control the cost workers’ compensation premiums charged to employers.

The MAXIMUS IMR solution is an efficient, expedient process for resolving disputes over the appropriateness of medical treatment recommended by physicians for injured workers, but rejected in the utilization review (UR) process. It replaces the previous, labor-intensive process that had required opposing medical experts to present testimony to non-clinical judges who rendered decisions.

Individual cases are routed to an independent health care professional — including nurses, doctors, physical therapists, health appeals specialists and other professional health clinicians. The reviewer is screened to ensure they have no conflict of interest with the parties in the case. The expert reviewers follow the principles of evidence-based medicine (EBM) to determine if the requested treatment is medically necessary.

The MAXIMUS IMR solution showcases many of our digital transformation capabilities, including the use of technology, data and analytics to automate and streamline the process using business rules at the core of the IMR. These business rules guide and aid the reviewers in their work to ensure recommendations and treatment decisions are based on the best available peer-reviewed and epidemiological evidence.

In California, the IMR document collection portal has processed over a million pieces of information and can easily scale to add millions more. We also provide analytics on the data that enables the State to more easily identify potentially fraudulent cases.

When the IMR program launched in California, initial estimates were that it would handle 2,000 – 4,000 cases per month, however it has received more than 15,000 cases every month. The IMR portal enabled MAXIMUS to process the initial backlog and prevent future ones, while greatly reducing the processing time and cost to the State.