Wis. Commissioner Issues Health Insurance Appeals Report

June 12, 2003

Wisconsin’s Office of the Commissioner of Insurance (OCI) has issued its report on 2002 Independent Review requests. The report documents the total number of review requests, the Independent Review Organizations (IROs) involved, the average number of days to resolve the case, and the determination of the IRO.

Three IROs, the Medical Review Institute of America, Permedion and Maximus-CHDR examined Wisconsin cases. Insurers’ decisions were reversed or partially reversed 42 percent of the time. Nationally, IROs overturn insurers’ decisions 40 to 60 percent of the time.

Independent review disputes must involve a medical judgement, and the total cost of the denied coverage must exceed $250. Therefore, even though there were 193 requests received by the IRO organizations in 2002, only 180 actually qualified for review.

Enacted in 2002, the independent review process allows policyholders who are unhappy with their insurance company’s decision to deny coverage to appeal to an IRO. The review process is intended to be the final step in a grievance process, after consumers have exhausted their insurer’s internal grievance system. Under the IRO arrangement, medical professionals with no relation to the insurance plan evaluate the claimant’s medical situation and decide whether to uphold or overturn the insurer’s decision. The IRO decision is binding on both the insured and the insurer.

The independent review process is designed to resolve disputes between claimants and their insurance company in a timely manner. Once cases are submitted, IROs have 30 days to complete their review, although the process can be expedited if necessary. In 2002, eight reviews were done on an expedited basis and they were all completed within three days.

The 2002 report is the first full-year report of the IRO process.

A copy of the 2002 report is available on OCI’s Web site at http://oci.wi.gov/iro/rpt_2002.htm, and a fact sheet on the IRO process is available at http://oci.wi.gov/pub_list/pi-203.htm.

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