Independent Review Requests
for Calendar Year 2002
According to State insurance law, health insurance claimants have a right to an independent review of an adverse decision by an insurer of their claims. These reviews are carried out by Independent Review Organizations (IROs) registered with OCI. Every year, IROs certified to do reviews in Wisconsin are required to submit to the Office of the Commissioner of Insurance an annual report for the prior calendar year's experience. The independent review process allows a consumer to appeal some health insurance claims denials to an independent third party. This process became available June 15, 2002. The results from the first year's reports are summarized below.
A total of 193 review requests were submitted to the 3 certified IRO's for consideration. In 13 cases, the IRO declined the request. A review request may be declined for a number of reasons. If the request does not involve a question of whether the treatment is medically necessary or whether it is experimental, it is not eligible for an independent review. An IRO may also decline a review if it determines that it may have a potential conflict of interest or if it receives a request directly from a consumer rather than from the insurer.
The last column of the summary lists the average number of days that the IROs needed to complete a review. Although the time needed to make a decision varies depending on the complexity of the case, on average an IRO took 22 days from the date it received the review request to make a decision.
OCI will be refining this report as more data becomes available and as we get suggestions for improvement to the report from those who use it. You are encouraged to contact OCI with your suggestions.
The Fact Sheet on the Independent Review Process in Wisconsin provides more information about this process. It can be found at http://oci.wi.gov/pub_list/pi-203.htm. You can also contact OCI at the address on the How to Contact Us page to request a copy.
Independent Review Organizations Certified to Perform Independent Reviews in Wisconsin
| Insurance Company | Review Requests Received | Independent Review Organizations | Number of Decisions | Average Number of Days to Resolve |
|---|
| Medical Review Inst of America | Permedion | Maximus-CHDR | Upheld | Reversed |
|---|
| Blue Cross & Blue Shield United of WI * | 29 | 14 | 14 | 1 | 20 | 8 | 22 |
| Compcare Health Services Ins Corp | 11 | 3 | 8 | 0 | 7 | 4 | 26 |
| Dean Health Plan | 14 | 2 | 11 | 1 | 9 | 5 | 31 |
| Federated | 1 | 0 | 1 | 0 | 0 | 1 | 32 |
| Group Health Coop of South Central WI | 2 | 0 | 2 | 0 | 2 | 0 | 28 |
| Gundersen Lutheran Health Plan * | 4 | 1 | 3 | 0 | 2 | 1 | 20 |
| Humana Insurance Company | 4 | 1 | 3 | 0 | 1 | 3 | 27 |
| Humana Wisconsin Health Organization | 2 | 1 | 1 | 0 | 1 | 1 | 20 |
| MercyCare Insurance Comp * | 3 | 0 | 2 | 1 | 2 | 0 | 22 |
| Midwest Security Life Ins Comp * | 20 | 8 | 12 | 0 | 11 | 8 | 17 |
| Network Health Plan | 1 | 0 | 1 | 0 | 1 | 0 | 14 |
| Physicians Plus Insurance Corp * | 7 | 3 | 4 | 0 | 3 | 2 | 18 |
| PHP Insurance Plan | 1 | 1 | 0 | 0 | 1 | 0 | 7 |
| Security Health Plan | 12 | 1 | 11 | 0 | 9 | 3 | 31 |
| Touchpoint Health Plan * | 21 | 7 | 12 | 2 | 11 | 7 | 15 |
| UnitedHealthCare of Wisconsin | 4 | 0 | 4 | 0 | 2 | 2 | 22 |
| Unity Health Plans | 5 | 1 | 4 | 0 | 3 | 2 | 23 |
| United Wis Life Insurance Company | 3 | 1 | 2 | 0 | 0 | 3 | 32 |
| Wisconsin Auto & Truck Dealers Insurance | 1 | 1 | 0 | 0 | 0 | 1 | 24 |
| WEA Insurance Trust | 1 | 1 | 0 | 0 | 0 | 1 | 29 |
| Wisconsin Physicians Service Ins Corp * | 47 | 27 | 20 | 0 | 19 | 24 | 21 |
| Totals | 193 | 73 | 115 | 5 | 104 | 76 | 22 |
| * | Total review requests received does not equal total number of decisions because Independent Review Organization declined one or more cases. |
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