Last Updated: May 2, 2014
A total of 51 review requests were submitted to the 9 certified IROs for consideration. In 7 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. In addition, in 1 case the insurer reversed its decision before the IRO completed its review.
The time needed to make a decision varies depending on the complexity of the case. On average an IRO took 26 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 2013, three cases were reviewed on an expedited basis and the IRO made its decision within 1 day.
|Independent Review Organizations||Number of Decisions|
|Dean Health Plan ||4||0||0||0||0||0||4||0||0||0||4||0|
|Humana Ins. Co.||4||3||0||0||0||0||0||1||0||0||4||0|
|MercyCare Ins. Co.||1||0||0||0||0||0||1||0||0||0||1||0|
|Network Health Plan ||1||0||0||0||0||0||1||0||0||0||1||0|
|Time Ins. Co.||1||0||0||1||0||0||0||0||0||0||1||0|
of Wisconsin *
|US Health and|
Life Ins. Co.
|WEA Insurance Corp.||11||0||2||2||0||0||4||0||3||0||9||2|
|WPS Health Plan||1||0||0||0||0||0||0||1||0||0||0||1|
* Total review requests received do not equal total number of decisions because the Independent Review Organization declined one or more cases.
** In one case the insurer reversed it denial prior to IRO review.
Independent Review Organizations Annual Reports main page.