IMRs in California Accepted by CMS in Carr Allison MSA Allocations

Under California workers' compensation law, as of July 1, 2013, medical treatment disputes for all dates of injury are resolved through the Independent Medical Review (IMR) process. Specifically, Section 4610.6(g) of the California Labor Code provides that "[t]he determination of the independent medical review organization shall be deemed to be the determination of the administrative director and shall be binding on all parties."

As a general matter, CMS should recognize a binding decision on the merits under state law that certain treatment or prescriptions are not compensable.  However, last year we discussed the IMR process with CMS and were informed that the WCRC, the CMS contractor that reviews MSAs, had not been giving appropriate consideration to IMR Final Determinations in cases submitted by other vendors.  The contractor simply did not understand the binding nature and legal effect of IMR Final Determinations.

Carr Allison was at the forefront of discussions with CMS regarding IMR Final Determinations and WCMSA policy, explaining the IMR process and applicable section of the California Labor Code to the CMS Central Office.  We are pleased that those efforts paid off, as CMS has recognized IMR Final Determinations following our discussions.  In fact, in a very recent case, we negotiated a $66,438 MSA reduction with CMS based on the findings of an IMR Final Determination.  CMS agreed to exclude medications that were found by the IMR Final Determination to not be reasonable or necessary.

As a law firm, we are committed to aggressively advocating to CMS any legal basis for reducing MSAs.

If you have any questions about reductions based on IMR Final Determinations or applicable state laws, please do not hesitate to contact us.