Date: July 13, 2004
For more information contact: Eileen Mallow, Assistant Deputy Commissioner, (608) 266-7843 or eileen.mallow@wisconsin.gov

2003 Health Insurance Appeals Report Issued

Madison, WI--According to a new report issued by the Office of the Commissioner of Insurance (OCI), Wisconsin residents appealed 220 health insurer decisions to independent review organizations (IROs) in 2003. In more than a quarter of those cases, the IRO ruled in favor of the claimant--fully or partially reversing the insurer's denial of coverage.

"The IRO process can help people get the care they need if they are not satisfied with their insurer's decision," said Barbara Belling, OCI Managed Care Specialist.

Enacted by the state legislature in 2002, the IRO process allows insureds who have exhausted their insurer's internal grievance process to ask for an independent opinion. Cases submitted to IROs are examined by medical professionals who evaluate the claimant's medical situation and decide whether to uphold or overturn the insurer's ruling.

"All too often, people assume their denial was the result of managed care bureaucracy," said Belling. "Appealing to an IRO removes this fear and provides them with the peace of mind that their case was closely examined and a decision was made on the merits of their particular situation."

The independent review process is designed to resolve disputes between claimants and their insurance company in a timely manner. Independent review requests must be completed within 30 days once they are received, although cases may be done more quickly if necessary. On average, IROs took 18 days per case to reach a decision in 2003.

"IROs act as the final arbiters in health care disputes. I hope more and more Wisconsin residents take advantage of the process and it helps bring closure to their health care grievances," Belling said.

Persons wishing to appeal their case should select an IRO from the list enclosed with the insurer's final written decision, and return that selection along with a written statement to the insurer requesting independent review of the case. Each IRO request costs $25, although the fee is returned if the IRO rules in the insured's favor. The decision made by the IRO is binding on both the insured and the insurer.

To qualify for the IRO process, the total cost of denied coverage must exceed $250, and the IRO must not decline the insured's review request. Cases may be declined by an IRO for a number of reasons. First, in order to be eligible for independent review, requests must involve a question of whether a treatment is medically necessary or whether a treatment is experimental. Second, reviews may be declined if the IRO believes that it may have a potential conflict of interest. Third, cases may be denied if the IRO receives the request directly from an individual, rather than properly routing the request through the insurer as required. Therefore, although 220 cases were submitted to IROs in 2003, only 178 qualified for review. In cases where no ruling was given, such as an IRO declining because of a conflict of interest, insureds were allowed to submit their case to a different IRO.

In 2003, five IROs were certified to perform independent reviews in Wisconsin: IPRO, Maximus-CHDR, the Medical Review Institute of America, Permedion and Prest. To receive certification from OCI, an IRO must demonstrate that it is unbiased and has procedures in place to ensure that its clinical peer reviewers are qualified and independent. Recertification of IROs is performed by OCI biannually.

The complete 2003 IRO report is available on OCI's Web site at http://oci.wi.gov.

More information about the IRO process is available in OCI's Fact Sheet on the Independent Review Process in Wisconsin. The sheet is available online or may be requested by calling 1-800-236-8517, e-mailing ociinformation@wisconsin.gov, or writing P.O. Box 7873, Madison, WI 53707-7873.

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.