Top Workers’ Compensation Attorneys’ Blog

Recent Changes Improve Workers Compensation Treatment Approval Rate

There is great news on the horizon for injured California workers. A study of recent changes to the workers compensation system initiated by the California Workers’ Compensation Institute (CWCI) shows that approval rates have risen dramatically. The study compared approval rates before and after the adoption of changes that streamline the medical review and approval process. In fact, according to the study, California workers compensation system now boasts that 94.1% of the medical services that were either requested or performed on injured workers were either approved (92.5%) or approved with modifications (1.6%).

California Workers’ Compensation Institute Study

The California Workers’ Compensation Institute (CWCI) has long been focused on improving the efficiency of workers compensation procedures. In 2013, a number of changes were made to the system that were designed to increase its effectiveness. The recent study focused on the 10 month period that followed the implementation of additional protocols altering the utilization review and independent medical review processes in 2018.

Of particular focus was the adoption of a prescription drug formulary based on evidence-based guidelines (authorized by AB 1124). The drug formulary allowed certain drugs that had previously required utilization review. Other changes pertained to exemptions for services provided within a 30-day window of the initial injury, and other basic services rendered by Medical Provider Networks that fall within evidence-based guidelines, exempting certain drugs from prospective UR. And finally, it instituted changes mandated by SB 1160 that allow UR exemptions for emergency services and most medical services provided within 30 days of injury, as well as basic services performed by Medical Provider Network providers that meet evidence-based guidelines.

Workers Compensation Treatment Approval for Drugs

Pharmaceutical approval was another area covered by the CWCI study. It noted that 88.1% of requested prescriptions were approved by utilization review; 2.6% were approved with some modification, and merely 9.2% were denied. After independent medical review (IMR), 10.6% of those denials and modifications were overturned, elevating the total approval rate for prescriptions to 88.6%.

Some pharmaceutical categories have held traditionally high denial rates. These include anti-inflammatories (2.9%), which are now exempt under the formulary; dermatologicals (18%) and drug therapies for musculoskeletal injuries (20.9%). Opioids continue to earn high denial and modification rates of approximately 17.4% and 8.2%, respectively. The modifications tend to involve either a reduction in the quantity of opioids prescribed, or the number of refills allowed.

What This Means for Workers Compensation Recipients

A review of IMR decisions from 2014 to the present indicates a decline in determination letters during the first half of 2019. This decline places the numbers back to where they were in 2015-2017, reversing an increase seen in 2018. This review also showed that 11.8% of the 2019 IMR decisions related to utilization reviews that approved the requested service, but modified either the quantity or duration to comport with evidenced-based standards.

Because these IMR modifications tended to be upheld, there is some consideration being given to barring IMR submissions if a UR modification already conforms to evidence-based standards.

Top Workers Compensation Attorneys – Long Beach, CA

Our attorneys will continue to monitor the details, analysis, and graphics from these and other studies. However, the positive trend revealed in this recent study bodes very well for Workers Compensation claimants’ ability to obtain the medical benefits they so richly deserve.

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