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OAL (Office of Administrative Law) Nod for CA DWC’s Final Versions of the IMR and IBR Regulations The Office of Administrative Law has approved both the IMR and IBR regulations. Both sets of regulations have been filed with the Secretary of State on February 12, 2014 and are effective immediately. Senate Bill 863 is California’s landmark workers’ compensation reform signed by Governor Edmund G. Brown Jr. in 2012, which has the objective of saving businesses millions of dollars in unnecessary costs while simultaneously improving worker protections. According to DIR (Department of Industrial Relations) director Christine Baker, “these reforms are engineered to reduce unnecessary costs while redirecting some of the savings to increase benefits for disabled workers." On January 1, 2013 the key components of Senate Bill 863 became law and included a 30% increase in permanent disability indemnity rates for workers phased in over two years. Other aspects of the bill such as those designed to reduce costs for businesses are being implemented through regulatory action. The DIR was established to boost working conditions for California’s workers and also to improve opportunities for profitable employment in California. A division within DIR, the DWC (Division of Workers’ Compensation) monitors the administration of WC claims and provides administrative as well as judicial services to help resolve http://www.mosmedicalrecordreview.com/
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disputes that arise in relation to workers’ compensation claims. The DWC has the following achievements to its credit as a result of its focus on implementing SB 863. •
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Adopted regulations such as: o Lien filing fee and activation fee o QME (Qualified Medical Evaluation) o Supplemental job displacement benefit (SJDB) o Interpreter certification process o IBR (Independent Bill Review) o IMR ( Independent Medical Review) Revised the inpatient hospital fee schedule to reduce duplicate payments for spinal implant surgeries. Revised the ASC (Ambulatory Surgical Center) fee schedule, thereby reducing the payment from 120% to 80%. Implemented the medical RBRVS (resource-based relative value scale) fee schedule effective from January 1, 2014. Started formal rulemaking for the predesignation/chiropractor primary treating physician regulations. Began formal rulemaking to revise the MPN (medical provider network) regulations.
IMR and IBR Regulations The (DWC) filed the certificate of compliance for IMR (Independent Medical Review) regulations and the IBR (Independent Bill Review) regulations on December 20, 2013 with the Office of Administrative Law (OAL). These were the last 2 sets of emergency regulations implementing SB 863. http://www.mosmedicalrecordreview.com/
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IMR (Independent Medical Review) is an efficient process through which all medical treatment disputes will be resolved by physicians. This will help avoid the more arduous and costly adjudication system. If the utilization review delays, denies or modifies a treating physician’s request for a specific course of medical treatment on the grounds that the treatment is not medically necessary, the injured employee has the right to request a review of that decision via IMR conducted by a physician. This evaluation which involves a detailed medical record review of the relevant medical records will be prompt and based on evidence-based standards to ensure that the injured employee receives appropriate and timely medical treatment. The IBR applies to any medical service bill where the fee is determined on the basis of a fee schedule adopted by the DWC. An IBR can be requested by a medical provider who disagrees with the amount paid by a claims administrator on a properly documented bill after a second review. This regulation can help eliminate costly, unnecessary litigation.
Core Inclusions in OAL-approved IMR and IBR Regulations The OAL has approved both the IMR and IBR regulations. Both sets of regulations have been filed with the Secretary of State on February 12, 2014 and are effective immediately. Before March 1, 2014 any version of the IMR application form adopted by the Administrative Directory under section 9792.10.2 can be used. The following are included in the final IMR regulations: http://www.mosmedicalrecordreview.com/
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Improved instructions and revisions to the IMR application form. Provision for penalties to be assessed against an administrator of claims for not producing medical records in a timely manner. Clarification that IMR determination cannot be based solely on the information provided by a UR (utilization review) determination.
Here are the inclusions in the final IBR regulations: • Consolidation of separate IBR requests has been limited to 20 requests. • Required index of supporting documentation. • Revisions made to the forms providers use to request a second bill review and IBR. • Electronic Medical Billing and Payment Companion Guide and the California Division of Workers’ Compensation Medical Billing and Payment Guide – updated versions. Comprehensive details regarding workers’ rights and employers’ responsibilities, and information for small business owners, are available on the DIR website. Their rulemaking webpage carries a quick overview of important regulations. The page is updated regularly.
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