Department of Labor and Industry

Medical Regulations Unit

U & T Guidelines Project

Independent Medical Review Request Form

The Independent Medical Review Request Form is currently available in an Adobe PDF file for downloading and printing. To return the form, you may:

  • Scan and return by e-mail to:·mlytle@mt.gov
  • Fax the form to:  Employment Relations Divison, ATTN:  Maralyn Lytle, 406-444-7710
  • Mail the form to:  Employment Relations Division, ATTN:  Maralyn Lytle, PO Box 8011, Helena, MT  59604

  

Questions?  E-mail Maralyn or call her at 406-444-6604

Download the form here:

Independent Medical Review Request Form

 

ePass Montana is a convenient and secure way to send Medical Records with the Independent Medical Review Request.

Go to this link, https://app.mt.gov/epass/epass,  to set up an ePass Montana account and bookmark it in your favorites.  ePass Montana is for State of Montana Business only.  Using the File Transfer Service, send all documents to the following email address:   mlytle@mt.gov

Montana Utilization and Treatment Guidelines

Independent Medical Review Process

What is the Independent Medical Review Process?

The Medical Director’s review and recommendation is an informal alternative dispute resolution process without administrative or judicial authority and is not binding on the parties.  The provisions of this rule apply to medical services provided on or after July 1, 2011.

Who is the Medical Director?

The Medical Director is the specific individual designated by the department to review the medical records submitted for denied authorizations of treatment that have been denied for treatment of an injured worker.  The Medical Director may seek consultation from other providers with specialties as would typically manage the type of medical condition being reviewed.  If a consultation is sought and received, that provider’s recommendation is also subject to the provisions that govern the Medical Director.  A person serving as a medical director must be a physician licensed by the State of Montana under Title 37, Chapter 3, MCA.

The Medical Director may not be called to testify in any proceeding concerning the issues discussed in the Independent Medical Review process.  Any recommendations and any information contained in the recommendation that is solely from the Medical Director or Specialists consulted are not admissible as evidence in any action subsequently brought in any court of Law.  The Medical Director's recommendation, including information contained in the recommendation, may be considered in mediation conducted under 39‑71‑2401, MCA.

What issues qualify for an Independent Medical Review Process?

A denied prior authorization obtained in cases where treatment(s) or procedure(s) are requested that:

(a)  are not specifically addressed or recommended by the Montana Guidelines for a body part that is covered by the guideline;

(b)  are after maximum medical improvement;

(c)  are beyond the duration and frequency limits set out in the guidelines; or

(d)  the guidelines require prior authorization before proceeding with the treatment.

How do I request an Independent Medical Review?

The interested party or insurer must submit their request for review to the department and notify the other party of the request for the review.  Complete the Independent Medical Review Report Form (IMR) and the insurer must submit a copy of the request for prior authorization, the denial, and any medical records to the department and the party requesting the review.   The interested party and the insurer may also submit additional information to the department that is relevant to the Independent Medical Review.  Any new information submitted to the department must also be submitted to the other party.

The Medical Director Review?

The Medical Director may, within 5 days of receipt of the Independent Medical Review, request additional time for review or may request additional medical records and then issue a written recommendation to the interested party and the insurer by mail, facsimile, or e-mail not to exceed 14 days from date of receipt of the request.  If the medical director does not issue a recommendation within 14 days, the request for review is deemed denied and the parties may proceed to mediation.

Keep in mind this is an informal alternative to the dispute process without administrative or judicial authority and is not binding on both parties.

The Insurer Responsibility?

The insurer shall, within five days of receipt of the recommendation, notify the interested party, if the previously denied treatment(s) or procedure(s) is authorized based on the Medical Director's recommendation.   If the insurer does not authorize treatment after issuance of the medical director's recommendation, the interested party may file for mediation with the department pursuant to 39-71-2401, MCA.

Submit Independent Medical Review requests to:

Maralyn Lytle, Claims Analyst Specialist
Employment Relations Division
Department of Labor & Industry
Independent Medical Review
PO Box 8011
Helena, MT  59604
Phone: (406) 444-6604
mlytle@mt.gov

Minutes August 19, 2009

Minutes

U & T Guidelines Project

Medical Provider Group Meeting
August 19, 2009
12:30 p.m., Great Northern Hotel, Helena

MPG members present: Alan Dacre, MD, Jim English, PHD, Ken Carpenter, MD, Pat Galvas, DO, Steve Kemple, DO, John Petrisko, MD, Allen Weinert, Jr., MD, Paul Gorsuch, MD, Valerie Benzschawel, CFNP, Phillip Steele, MD, Mark Stoebe, DC, Gary Lusin, PT (participating by phone)

Project team members present: Jerry Keck, Anne Wolfinger, Diana Ferriter, Keith Messmer, Bruce Chamberlain, Ting Withers, Lea Coles

Others present: Keith Kelly, Department of Labor & Industry; Erin Sexton, Medtronic; Andy Adamek, Browning, Kaleczyc, Berry & Hoven; Bridget McGregor, Tom Martello, Peter Strauss, Montana State Fund; Laura Merchant, Benefis; Pat Murdo, Legislative Services; Bob Olsen, Montana Hospital Association; Bruce Spencer, Property Casualty Insurance Association; Jacqueline Lenmark, American Insurance Association; Jon Bennion, Montana Chamber of Commerce; Karen Wiles, Anni Druce, Dave Elenbaas, Donna Kamany, Employment Relations Division

I. Welcome and Introductions
Keith Kelly, Commissioner, Montana Department of Labor and Industry, greeted those present and thanked the committee members for their willingness to participate on this important project. He pointed out the high level of spending on medical services and the national debate on healthcare occurring. Dr. Dacre, committee chair also thanked everyone for their participation and had everyone introduce themselves.

II. Summary of the Workers’ Compensation Study Project
Jerry Keck, Administrator, Employment Relations Division, gave a presentation of the work of the Department and the Workers’ Compensation Labor-Management Advisory Council (LMAC) to identify the causes of Montana’s high premium ranking, which as of 2008 were second highest in the nation according to an Oregon premium ranking study. He reported that medical spending now accounts for 70 cents of every dollar spent in Montana for workers’ compensation benefits.

III. Montana Workers’ Compensation Data
Ting Withers, Workers’ Compensation Analyst, Employment Relations Division, gave a presentation on the most costly injuries in the workers’ compensation system based on data collected from insurers.

IV. Medical Provider Group Charter
Anne Wolfinger, Project Manager, Employment Relations Division, walked the committee through the project charter that the group will be operating under for this project. She reviewed various parts of the charter including the project purpose, objectives, scope, project authority and roles and responsibilities. She pointed out that developing new utilization and treatment guidelines from scratch was out of the scope of this committee because of the limited resources available. She also reviewed the proposed timeline which has the group developing a recommendation by December 16, 2009.

V. Medical Provider Group Review Process
Jerry Keck and Anne Wolfinger reviewed the “How to Select Medical Treatment Guidelines for Workers’ Compensation” outline which was developed from a presentation given by Dr. Teryl Nuckols at the Department of Labor and Industry’s Workers’ Compensation Educational Conference in January. The document outlined the considerations in selecting guidelines, the California approach used and the approach proposed by the Montana project team. Each step was reviewed:

Step 1. Define the purpose of the guidelines:

The goal the project team developed was to improve quality of care while controlling costs. This was contrasted with the California approach which focused on controlling costs while maintaining quality of care.

Dr. Galvas asked if a treatment that is well accepted falls outside the guidelines, can we have agreement up front that this is appropriate treatment. Jerry answered that prior approval would need to be obtained from the insurer, just as is done now.

Gary Lusin asked if the Department had a definition of outcomes. Jerry explained that the team is working on how we can measure outcomes pre- and post-guidelines.

Dr. Carpenter asked if adoption was mandatory or if once adopted it became mandatory for providers to follow. Jerry responded that the adoption is at the discretion of the Department, but once adopted compliance would be mandatory.

Dr. Gorsuch stated that the guidelines should only be adopted if you can improve outcomes and stressed the importance of defining and measuring guidelines. Jerry replied that the project team will be trying to measure outcomes and reminded the group that one of the accepted criteria of good guidelines is that they are updated at least every three years.

2.         Assign Decision Making Authority: The Department of Labor and Industry has the ultimate authority to adopt the guidelines.

3.         Decide Whether to Use Existing Guidelines or Build Our Own: Anne stated it is cost prohibitive for Montana to develop our own guidelines.

4.         Choose Whether to Use One or Multiple Guidelines: Considerations

There are three options for the MPG to consider: adopt one comprehensive guideline set, select the single best guideline for each topic or allow multiple good guidelines per topic.

Gary Lusin asked if the guidelines could be for return to work rather than medical outcomes. Jerry commented that part of the ODG focuses on this approach with the Medical Disability Advisor.

5.         Specify Topics Guidelines Should Address:

The committee’s focus will be on quality of care first and cost control second reviewing the injury areas with the highest dollar costs for treatment. The Department is looking for the recommendations of the group.

Dr. Carpenter worked with Bruce Chamberlain to develop four scenarios of common injuries that will be given to those who explain each guideline and they will be asked to outline how these specific injuries are handled within the guideline.

Dr. Dacre said that he felt the data the Department currently gets will not help and there will be a need to collect different data which this group can help identify. Dr. Gorsuch agreed saying that he could see how many bad outcomes could occur from the guidelines. If this group could generate “how to measure outcomes,” that would help the group select the guidelines.

6.         Identify and Screen Candidate Guidelines:

The project team recommends looking at ACOEM, ODG and Washington State’s guidelines. The project team looked at Colorado, Washington and New York State guidelines and chose Washington because they were widely accepted with very little controversy.

Dr. Dacre said that there are others that are more disease specific. He would like to look at the North American Spine Society Guidelines to see if they might be more appropriate for the spine area. Dr. Carpenter said he had looked at them and found them to be similar to ODG. Anne said the committee could have until November to decide if they wanted to add more guidelines to review.

7.         Evaluate Guidelines Meeting Screening Criteria:

The project team recommended evaluating guidelines based on technical quality and clinical validity as well as format and presentation. The project team recommended using the AGREE instrument process for rating technical quality and the Rand/UCLA Appropriateness Method for evaluating clinical validity.

Dr. Gorsuch said Rand suggested rating based on strength of evidence and outcome data. He suggested that each of the presenters of the guidelines be asked to address what effect the review of the literature had on their findings. Anne stated that Dr. Carpenter had given her a chart explaining the different levels of evidence. Dr. Dacre said that he was familiar with a quality of evidence measure, HHRQ, which he will give to Anne to disseminate. Dr. Stoebe stated he will have to look at the evidence to make his own decision on the appropriateness of the evidence.

8.         Select the Guidelines to Implement:

The Department will select the guideline(s) using the recommendation of the committee. The committee should try and anticipate shortcomings of the guidelines and address how to deal with them.

9.         Disseminate Selected Guideline:

Implementation will be very important as the guidelines need to be made available to everyone in the system. The Department is responsible for distributing the guidelines.

10.       Assess Long-Term Effects of the Guidelines:

The guidelines will need to be evaluated on their effect on access to care, quality of care and costs. Evaluation criteria for measuring outcomes will need to be established.

Gary Lusin said that one of the important factors will be return-to-work. The guidelines could extend this time or put patients back to work to early. Jerry responded that the literature says most delay in return-to-work is medically unnecessary. The worker should not be returned until the doctor says it is ok, but you need to have good communication. Gary asked it this came under the role of this committee. Jerry said the RTW committee of WorkSafeMT will address this area, not this committee.

VII. Public Comment
Pat Murdo with the Legislative Council said that the Economic Affairs Interim Committee is following the work of this group and wants to hear from providers, employers and injured workers. Legislators on the committee have said they would be willing to look at incentives, such as if doctors didn’t have to do so many tests would care be cheaper. If so, they are willing to look at reducing litigation costs. Dr. Dacre said if the committee is willing to listen they could give them an earful.

Peter Strauss with the Montana State Fund outlined the cost drivers in workers’ compensation and said that MSF is appreciative of the members for giving of their time and effort and would help in any way they could.

Erin Sexton of Medtronic asked why the Washington State guidelines were being considered instead of other state guidelines. Jerry responded that the Department looked at Colorado and Minnesota. Colorado advised that Montana not look to adopt theirs as they are very time intensive to keep updated. The Minnesota guidelines as Jerry understood were based on the Washington State guidelines and are very similar. The Washington State guidelines are very attractive because they were well supported by everyone in the system. 

Bruce Spencer with Property Casualty Insurance Association (also representing Jacqueline Lenmark and the American Insurance Association) offered to help the committee.

VIII. Next Steps
Anne said the next meeting has been scheduled for September 16th at 12:30 at the same location. A representative from ACOEM will be making a presentation of the ACOEM guidelines.

It was brought up that the group had not reviewed the injury scenarios that Dr. Carpenter had developed. Dr. Dacre suggested that disc replacement be added to the fusion option in scenario 1. Dr. Stoebe recommended that a carpal tunnel scenario be added. Dr. Gorsuch asked for a whiplash scenario and Dr. Galvas suggested adding a head injury. Dr. Dacre commented that you need to take into account how many times this type of injury happens to determine if it is worth addressing. Dr. English said that scenarios that cross a variety of the guidelines would be helpful. Dr. Carpenter said he will take the suggestions and revise the scenarios.