Study examines workers' compensation approval rates in California

According to the California Workers' Compensation Institute's newest study, 94.1% of medical services requested or performed on behalf of injured workers have been approved since the 2018 changes to the system. The majority, 92.5%, were approved without modifications.

The changes to the Utilization Review (UR) process and the Independent Medical Review (IMR) system were the focus of those changes. Based on specific guidelines and a prescription drug formulary, certain drugs and treatments were exempt from URs in an effort to streamline the workers' comp process in general. The exemptions allow a time-saving workaround when requests for treatment can be approved without moving to a UR.

The study also sheds some light on what workers can expect if their requested treatment is denied -- particularly where medications are concerned. The type of medication your doctor wants to prescribe often dictates the chance that the request will be denied. Anti-inflammatory drugs, for example, are denied only about 2.9% of the time for being inappropriate or not medically necessary, while opioids (which have become the bugbear of insurance companies everywhere these days) are denied 17.4% of the time. They're also the number one cause of modified approvals, at 8.2%, with insurers restricting either the dosage or number of refills allowed.

This is mixed news for injured workers. While it does indicate that a worker with standard injuries who needs standard care can probably access care faster, the use of formularies always bodes ill for anyone who has a complicated condition or a condition that just doesn't respond as expected to the standard treatments.

If you're having trouble working through the complexities of your workers' compensation claim, you don't have to go it alone. Find out how you can obtain help with your claim.

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