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.
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 |
|---|
| Dean Health Plan | 4 | 0 | 0 | 0 | 0 | 0 | 4 | 0 | 0 | 0 | 4 | 0 |
Federated Mutual
Ins. Co. | 2 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 1 | 1 | 1 |
Golden Rule
Ins. Co. | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 0 |
Health Tradition
Health Plan | 2 | 0 | 0 | 0 | 0 | 0 | 2 | 0 | 0 | 0 | 2 | 0 |
| HIRSP ** | 4 | 0 | 1 | 2 | 1 | 0 | 0 | 0 | 0 | 0 | 3 | 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 |
Physicians Plus
Insurance Corp* | 11 | 0 | 0 | 11 | 0 | 0 | 0 | 0 | 0 | 0 | 2 | 3 |
| Time Ins. Co. | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
UnitedHealthcare
Ins. Co. | 4 | 0 | 0 | 0 | 1 | 0 | 3 | 0 | 0 | 0 | 4 | 0 |
UnitedHealthcare
of Wisconsin * | 3 | 0 | 0 | 0 | 1 | 0 | 0 | 0 | 1 | 1 | 2 | 0 |
US Health and
Life Ins. Co. | 1 | 0 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 |
| 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 |
51 |
3 |
3 |
17 |
3 |
0 |
16 |
3 |
4 |
2 |
35 |
8 |
* 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.
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