Last Updated: May 1, 2015
A total of 54 review requests were submitted to the 9 certified IROs for consideration. In 4 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 24 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 2014, seven cases were reviewed on an expedited basis and the IRO made its decision within 2 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 |
|---|
American Family
Mutual Ins. Co. | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 0 |
American Republic
Ins. Co. | 5 | 1 | 0 | 0 | 0 | 4 | 0 | 0 | 0 | 0 | 5 | 0 |
| Dean Health Plan | 5 | 0 | 0 | 0 | 0 | 0 | 5 | 0 | 0 | 0 | 5 | 0 |
Federated Mutual
Ins. Co. | 2 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 1 |
Golden Rule
Ins. Co. | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 |
Health Tradition
Health Plan | 3 | 0 | 0 | 0 | 0 | 2 | 1 | 0 | 0 | 0 | 2 | 1 |
| Humana Ins. Co. | 9 | 8 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 8 | 1 |
| MercyCare HMO* | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 |
| Network Health Plan | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 0 |
Physicians Plus
Insurance Corp* | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
UnitedHealthcare
Ins. Co. | 5 | 0 | 0 | 2 | 0 | 0 | 3 | 0 | 0 | 0 | 4 | 1 |
UnitedHealthcare
of Wisconsin | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 |
Unity Health
Plans Ins. Corp. | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 1 | 0 |
| WEA Insurance Corp | 10 | 0 | 4 | 5 | 0 | 0 | 1 | 0 | 0 | 0 | 5 | 5 |
| WPS Health Plan* | 2 | 0 | 0 | 0 | 0 | 0 | 2 | 0 | 0 | 0 | 0 | 1 |
Wisconsin Physicians
Services Ins. Corp. ** | 6 | 0 | 0 | 3 | 0 | 0 | 3 | 0 | 0 | 0 | 3 | 1 |
| Totals |
54 |
9 |
5 |
12 |
0 |
8 |
18 |
2 |
0 |
0 |
38 |
11 |
* Total review requests received do not equal total number of decisions because the Independent Review Organization declined one or more cases.
** Total review requests received do not equal total number of decisions because Independent Review Organization declined one case and in one case the insurer reversed its denial prior to IRO review.
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