Last updated: May 2, 2013
In 2012 a total of 69 review requests were submitted to the 9 certified IROs for consideration. 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. In 5 cases, the IRO declined the request.
The time needed to make a decision varies depending on the complexity of the case. On average, in 2012, 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, 3 cases were reviewed on an expedited basis and the IRO made its decision within 3 days.
Name of
Insurance Company | Total
Review
Requests
Received | Independent Review Organizations | Number of Decisions
that IRO: |
|---|
Adv.
Med.
Review | IPRO | Maximus | MCMC | Med.
Cons.
Network | Medical
Review
Inst. of
America | National
Medical
Reviews | Permedion | Prest | Upheld | Reversed |
|---|
Blue Cross Blue
Shield of WI | 6 | 0 | 2 | 0 | 0 | 0 | 0 | 0 | 4 | 0 | 3 | 3 |
| Dean Health Plan | 2 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 |
Federated Mutual
Ins. Co. * | 5 | 0 | 0 | 1 | 0 | 1 | 1 | 0 | 2 | 0 | 3 | 1 |
Golden Rule
Ins. Co. | 2 | 0 | 0 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 2 | 0 |
Group Health Coop
of Eau Claire | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 1 |
Group Health Coop
of South Central WI | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 |
| Gundersen Health Plan | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
Health Tradition
Health Plan | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | 0 | 1 | 0 |
| HIRSP | 4 | 0 | 0 | 1 | 0 | 2 | 0 | 0 | 1 | 0 | 3 | 1 |
| Humana Ins. Co. | 4 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | 0 | 3 | 1 |
Independent Care
Health Plan * | 2 | 0 | 0 | 2 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Natl. Union Fire
of Pittsburgh | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
| Network Health Plan | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 |
Nippon Life Ins.
Co. of America | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 |
| Pekin Life Ins. Co. | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 0 |
| Physicians Plus Insurance Corp. * | 2 | 0 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 |
Security Health
Plan of Wisconsin | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 |
Thrivent Financial
for Lutherans | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
| Time Ins. Co. | 2 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 2 | 0 |
UnitedHealthCare
Insurance Company | 6 | 0 | 1 | 0 | 1 | 0 | 1 | 0 | 0 | 0 | 5 | 1 |
UnitedHealthcare
of Wisconsin | 3 | 0 | 2 | 3 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 2 |
Unity Health Plans
Insurance Corp. | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
| WEA Insurance Corp. | 12 | 0 | 2 | 3 | 0 | 0 | 3 | 0 | 4 | 0 | 11 | 1 |
Wisconsin Physicians
Service Ins. Corp. * | 8 | 0 | 2 | 3 | 0 | 0 | 1 | 2 | 0 | 0 | 5 | 2 |
| Total |
69 |
1 |
11 |
18 |
3 |
4 |
13 |
5 |
12 |
2 |
50 |
14 |
* Total review requests received do not equal total number of decisions because the Independent Review Organization declined one or more cases.
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