Date: April 15, 2009
For more information contact: Jim Guidry, (608) 264-6239 or jim.guidry@wisconsin.gov

Insurance Commissioner Reports on Independent
Review for Health Insurance Consumers

Madison, WI—The Office of the Commissioner of Insurance (OCI) recently issued its annual summary of requests by consumers of independent external review of adverse health insurer claim decisions.

"The independent review process has been a great consumer protection for Wisconsin residents," said Wisconsin Insurance Commissioner Sean Dilweg. "By having an organization that is not associated with the insurer review their decisions, consumers can be assured that they are getting fair decisions from their health insurers."

Wisconsin law gives health insurance claimants the right to an independent review of an adverse decision by an insurer of their claims once they have exhausted the insurer's grievance process. Adverse determinations include questions regarding experimental treatment, length of stay, and medical necessity. These reviews are carried out by Independent Review Organizations (IROs) certified by the Office of the Commissioner of Insurance. Every year, IROs are required to submit to the OCI a report summarizing the prior year's experience.

For calendar year 2008, a total of 110 review requests were submitted to the 6 certified IROs for consideration. Thirty-six of the review requests resulted in the independent reviewer reversing the insurer's decision, giving the insured some or all of what they requested. Insurer decisions were upheld in 64 cases. In 10 cases, the IRO declined the request.

An IRO may decline a request that does not meet the statutory definition of adverse determination or if the IRO believes it has a conflict of interest with the health insurer.

On average, IROs took 22 days from the date it received the review request to issuing 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.

For more information please see the OCI publication Fact Sheet on the Independent Review Process in Wisconsin. It can be found at http://oci.wi.gov/pub_list/pi-203.htm. You can also contact OCI at the 1-800-236-8517 or visit the agency's Web site at http://oci.wi.gov.

Created by the Legislature in 1871, Wisconsin's Office of the Commissioner of Insurance (OCI) was vested with broad powers to ensure that the insurance industry responsibly and adequately met the insurance needs of Wisconsin citizens. Today, OCI's mission is to lead the way in informing and protecting the public and responding to its insurance needs.