IMR, Chronic Pain Cases and 7/1/2013
The implications of IMRs now taking effect for all UR decisions taking place on and after 7/01/2013, regardless of the date of injury.
As you already know, Independent Medical Review (“IMR”) now takes effect not only for injuries occurring on or after 1/1/2013, but for all UR decisions taking place on and after 7/01/2013, regardless of the date of injury. Therefore, all medical necessity disputes over UR decisions to delay modify or deny medical treatment requests, shall be determined through the IMR process and not by either a QME or AME. This means that medical necessity issues will be taken out of the hands of the PQME’s and AME’s and placed into the exclusive realm of the IMR process. With but a few narrow exceptions, these IMR decisions will be binding and therefore final.
You know the claims. These are the cases, whose numbers you have committed to memory. These are the claims, whose physical claim file or computerized claim notes never seem to disappear from your work area or computer screen. It seems as if these claims generate a lot of handling activity but often not so much actual progress. In many instances, the applicant had one or more surgical interventions, but these did not go well. In the recovery aftermath, the PTP has either provided opioids or the applicant has changed to a treating physician, who is prescribing opioids for chronic pain. The monthly medical reports paint the same picture of chronic pain, but also affording, little or no actual relief from the pain.
Please recall that effective, 1/18/2009, the Administrative Director adopted the Chronic Pain Medical Treatment Guidelines [“CPMTG”] as part of the Medical Treatment Utilization Schedule [8 CCR 9792.20-9792.26] These guidelines, spanning some 127 pages, were supposed to be the benchmark for the treatment and management of chronic pain, including the use of opioids. The section actually dealing with the use and management of opioids is from PP 74 to 97. In these important 23 pages, the Administrative Director has prescribed the methods and standards under which opioids should be used, for the treatment of chronic pain. These topics include:  The definitions of long term use of opioids, (6 months or more),  A therapeutic trial;  Whether the pain is nociceptive or neuropathic;  Dosing;  Baseline pain and functional capacity assessment;  Patient agreements;  Screening for addiction;  Red flags for addiction;  Steps to take in order to avoid misuse;  Random urine toxicology screens;  Opioid management;  Weaning and tapering;  Whether the pain has become neuropathic.
Unfortunately, many PTP’s either simply ignore these treatment guidelines or they treat outside of the guidelines without any explanation or description of extenuating circumstances. As a result, you are well aware that many of these claims seem to be self-perpetuating with the applicant often refusing any plan to wean or to taper from the medications, so that in effect, they have become dependent upon the very medications which were otherwise intended to free them from their own pain. Instead, they are chronically tied to these medications because of dependency or possibly addiction and ironically, they still have their chronic pain, with very little if any notable relief. In many instances, the pain is very real, but it is pain coming not from the site of the injury (nociceptive) but rather it is pain emanating from the central nervous system. (Neuropathic). Unfortunately, many physicians who prescribe opioids, also fail to make this distinction and commonly do not present an actual “opioid treatment plan” which is consistent with the CPMTG. Seemingly, many physicians simply have an undefined, open-ended treatment plan or even no plan at all.
Understandably, some attorneys for the applicants are notably concerned about the new proliferation of IMR across all treatment requests (RFA’s) and especially those pertaining to the chronic pain cases where the applicants are continuing to take opioids, while their prescribing physicians continue to ignore or disregard the Chronic Pain Medical Treatment Guidelines. Here, we may have a very good opportunity to provide some forward movement in these chronic pain cases. Effective 7/1/2013, all requests for continued care for the opioid patient will go through UR and then any objections will be determined not by the opinion of the PTP, the QME or even the AME, but by virtue of the IMRO and the IMR process.
Your Utilization Review organization should have a strong understanding of the opioid guidelines contained in the Chronic Pain Medical Treatment Guidelines. Please recall that a basic concept within the CPMTG is that continued opioid use for the treatment of chronic pain should be tied to either an overall improvement of function, absent extenuating circumstances or a resolution of the pain.
Hopefully, when the RFA’s come in after 7/1/2013, the UR experts will be using the CPMTG among other things, in order to review requests for further use of opioids.
But, it is very important to note that the medical necessity of permitting further prescriptions for opioids needs to rest upon the physician using the CPMTG guidelines, and telling us whether the applicant is returning to function or being afforded actual long term pain relief, so the PR-2’s and narrative reporting in this regard are critical elements of the picture.
Defense attorneys need to be familiar with these guidelines so they can help shape questions for the applicant in depositions or questions for a physician deposition.
Objections to UR decisions to modify or deny requests for authorization, will then be sent through the IMR/IMRO process now established. Perhaps Maximus will be a “new set of eyes” on a big problem, which perhaps they have not been seeing up to now, because up until now, the IMR requests would have been only for the new cases, with a date of injury on or after 1/1/2013.
The expanded use of IMR, across all dates of injury, may provide a new opportunity to actually resolve some of these chronic pain cases by settlement.
Perhaps some of the applicant attorneys will regard the IMR application to these existing claims as a threat to their client’s continued and never-ending use of opioids for chronic pain. In this regard, settlement may become a more viable option.
Also, please keep in mind that many chronic pain cases are hampered, if not precluded, in settlement situations by extremely large MSA’s, based upon the lifetime use of opioids. If treating physicians become savvier about the proper use of opioids to treat chronic pain, perhaps we will be getting better outcomes if the PTP’s are more specific about the future limitations on opioids, rather than affording lifetime use for the treatment of chronic pain.
This is a good time to take inventory of your chronic pain cases and to see whether the use of the IMR process may actually have some good short term results but more importantly, perhaps affording you a better opportunity to address chronic pain on a long term basis, to encourage PTP’s to use the CPMTG before simply writing another prescription for an opioid.