Independent Review Requests
for Calendar Year 2012
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 the Office of the Commissioner of Insurance (OCI). Every year, IROs certified to do reviews in Wisconsin are required to submit to the OCI a 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. The results from the reports for calendar year 2012 are summarized below.
PLEASE NOTE: There is also a federal law that provides individuals with the right to an independent external review. Beginning in 2012, most health plans were required to follow the federal law. Independent reviews performed under the federal law may not be included in the reports submitted by the Wisconsin-certified IROs.
A total of 69 review requests were submitted to the 9 certified IROs for consideration. In 5 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 medical judgment, such as 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 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. An IRO will review a case on an expedited basis when a delay in obtaining treatment could jeopardize the health or life of the consumer. During 2012, three cases were reviewed on an expedited basis and the IRO made its decision within 3 days.
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.