Wisconsin health plan members who challenge adverse claim decisions have a 23% chance of prevailing.
The state’s insurance regulators have published the challenge outcome figures in a summary of 2006 independent review organization results.
The 5 certified IROs in the state received 184 requests for reviews, rejected 22 of the requests, and reversed 43 of the claim decisions that were reviewed, officials report.
The IROs took an average of 23 days to make their own determinations.
In Wisconsin, IROs cannot review decisions unless the decisions involve questions about whether a treatment is medically necessary or whether it is experimental.
An IRO also may decline to review a decision if it decides that it may have a potential conflict of interest or if it receives a request directly from a consumer rather than from the insurer, officials say.