Exposing The Independent Medical Review Scam in California Workers' Compensation

There is a disturbing reality in workers’ comp that is perilous to injured workers known as the independent medical review scam.

An independent medical review (IMR) is used to settle a dispute over the results of a physician’s exam called a utilization review (UR) for an employee seeking medical treatment from a work injury.

However, doctors that perform the independent medical examination (IME) are hired from within the insurance industry. These doctors often provide biased or inaccurate reporting that favor the employer. A work injury is downplayed to deny or reduce medical benefits. Essentially, there is never any real independent medical review conducted.

This post uncovers what can happen with IMRs in a workers’ comp claim so you can protect yourself and benefits.

Independent Medical Review Scam Table Of Contents:

  1. Unveiling the Independent Medical Review Scam
  2. How the IMR Process Works (and Why it Goes Wrong)
  3. Identify Potential Issues of an Independent Medical Review Scam
  4. Identify Potential Issues of an Independent Medical Review Scam
  5. Fighting Back Against the Independent Medical Review Scam
  6. Frequently Asked Questions on IMR in California Workers’ Compensation
  7. Conclusion

Unveiling the Independent Medical Review Scam

The IMR process aims to resolve medical treatment disagreements in workers’ compensation cases. It should be a neutral evaluation. But the system has been manipulated.

These “independent” doctors are paid by the employer’s insurance company. They are incentivized to minimize or deny an injury. They help to maintain an insurance company’s bottom line rather than assist the employee recover from their injury or illness.

How the IMR Process Works (and Why it Goes Wrong)

When there’s a dispute over treatment recovery, an IMR is requested for a case evaluation by a physician. However, repeating controversies continue to surface when independent medical reviews are conducted:

Conflicts of Interest
Doctors that perform IMRs are used by insurance companies, creating apparent bias to provide independent medical exam findings that benefit the insurer to maintain their business.

Exaggerated Findings
The doctor can downplay the extent of an injury, ignore relevant medical evidence, or diagnose a less severe condition than what the treating physician found in the utilization review.

Lack of a Thorough Examination
Some IME doctors may not conduct a comprehensive examination, relying solely on medical records and limited questioning. A paper review can easily or be deliberately misinterpreted.

Speedy Turnarounds
The speed of reporting also raises concerns. This may indicate inadequate utilization review time. Quick turnarounds undermine fairness for employees seeking accident support and long-term disability benefits.

A shoddy independent medical review is produced and an employee injured on the job gets scammed.

Thomas DeBenedetto, Workers’ Compensation Attorney, relays his experience on IMRs in CA and what you should do.

Real-Life Example of the Independent Medical Review Scam

Richard Decker was injured at work when an 80-pound commercial toilet fell on his head. He was employed by Kohler for over 35 years. Decker rightfully filed for worker’s compensation benefits to help cover his health care.

His claim to fair benefits was continually challenged. Decker’s case went to the state’s Labor and Industry Review Commission for a final decision. Four examining physicians concluded that Decker was permanently disabled from his injury. But the independent medical review examiners for the industry giant’s insurance company claimed his continued complaints of severe pain were just in his head and that he was healed. The commission found in favor of Kohler and against Richard Decker.

Decker has since developed a stutter, lives with constant pain and experiences memory loss after the incident. Today, he remains unemployed. He has no health plan. Decker is forced to survive on Social Security Disability Insurance at less than half his previous income for life’s expenses and long term medical care.

Richard Decker’s story isn’t unique. There are other similar cases. People like Steven Hofer , Norman McAtee , and Francis Stevens were unfairly denied when seeking a fair resolution through an IMR application with their employer insurance company.

The IMR scam has real consequences. Denied treatments, delayed recovery, and financial strain are just a few hardships that one may face. A person’s life, family and future can be devastated if a faulty IMR decision is not rectified.

Identify Potential Issues of an Independent Medical Review Scam

IMR cases have clearly shown that injured employees can be placed in horrible life situations. Don’t become one of them. Be aware and take note of:

Rapidly changing opinions
If the examining doctor significantly alters their diagnosis or health plan recommendations compared to previous evaluations that could indicate bias.

Disregarding medical evidence
If the doctor ignores relevant medical records or the utilization review results that support the worker’s claim could be a red flag.

Unusually quick evaluations
A very short IMR appointment can indicate a lack of thoroughness and potential for bias.

Fighting Back Against the Independent Medical Review Scam

If you suspect you’re an IMR victim immediately search for workers’ compensation attorneys with a free case evaluation. Also known as a work injury lawyer, consider attorney testimonials in your decision making. Hire the best workers’ comp attorney for you to provide invaluable assistance on the following:

  • Navigate the complicated IMR Process: This attorney is well-versed in legal guidelines of independent medical reviews across different healthcare contexts, including group health plans and workers’ compensation policies. The attorney will know how to address common issues associated with UR denials, navigate through IMR requests and getting your frequently asked questions about the independent medical review process answered
  • Challenge the Insurance Company IMR: The attorney will put medical evidence together to counter the insurance company IMR and fight for needed treatment. They can obtain expert second opinions from reputable physicians to support the disability claim.
  • Locate Health Care Services: As your claim moves forward your attorney can assist finding health care service options.
  • Negotiate with Insurance Companies: The attorney can skillfully negotiate with the insurance company for a fair settlement on your disability claim.
  • Litigate Your Case: Your attorney aggressively take your case to court to protect your rights related to your medical condition and ensure your medical care. For Hispanic speakers, some workers’ compensation attorneys in San Diego and Los Angeles offer IMR denied claims assistance in Spanish.

Frequently Asked Questions on IMR in California Workers’ Compensation

An IMR requests to appeal the decision of a utilization review (UR) when the medical benefits are modified, delayed or denied for an employee seriously injured or made ill at work.

The employer pays the cost of the IMR.

An appointed IMR physician conducts an evaluation of the injured employee’s condition. This typically includes:

  • A review of the employee’s medical history
  • Physical exam
  • Notes injury details, symptoms and any prior injuries or treatment.

A paper review of the medical findings, opinions on injury, and treatment plan if any is written.

If you disagree with the decision of a utilization review decision, you must seek IMR within 30 days of receiving the UR decision.

Conclusion

The independent medical review scam is clearly set to deprive injured workers of their rightful benefits and well-being. Don’t let the insurance company’s system get you. Fight back and hire an experienced workers’ compensation attorney proven with the IMR claims process. Ensure you receive the compensation and care you deserve.

If you’re struggling with an IMR decision or another issue affecting your workers’ compensation claim, you don’t have to navigate the process alone. An experienced San Diego workers’ compensation attorney can help you understand your rights, challenge unfair decisions, and pursue the medical care and benefits you deserve.

Thomas DeBenedetto, San Diego workers’ compensation attorney

Thomas DeBenedetto

Workers' Compensation Attorney

Thomas DeBenedetto has over 33 years of experience representing injured workers in California workers’ compensation claims. Based in San Diego, he focuses exclusively on workers’ compensation law and regularly publishes educational content to help injured employees understand their rights and benefits under California law.

Learn More About Thomas