More than $900K Recovered in Ohio Health Care Claim Reviews in 2009

Ohioans saved more than $900,000 in 2009 from health care claim denial appeals, the Ohio Department of Insurance announced.

The department produces an annual report on results under the Ohio Patient Protection Act. Since the enactment of the Act in 1999, 3,974 cases have been reviewed by the department or Independent Review Organizations (IROs), recovering more than $9.9 million in previously denied health care services for Ohio consumers.

The Act provides Ohioans with the opportunity to request an independent, external review for denial, reduction, or termination by their health insurer of certain health care services. Based on the reason for denial, the Act requires health insurers to provide for an external review by an accredited IRO or allow an affected consumer to request a contractual review by the Ohio Department of Insurance.

Health plan members, or a health care provider on behalf of the plan member, may request IRO review of health care services exceeding $500 where the denial is based on medical necessity or a determination that the service is experimental or investigative. All appeals must first go through a health insurer’s internal appeal process.

In 2009, 155 cases, involving benefit determinations of more than $2.2 million were submitted for IRO review. Of those cases, 38 percent were reversed by the IRO saving Ohio consumers more than $895,000.

The highest proportion of reviews were for surgery, oncology, psychiatry and chiropractic. A total of 139 cases were submitted to the department for contractual review, with 25 of those cases resulting in reversals savings Ohioans more than $31,000. A total of $26,497 was paid based on cases referred by the department for IRO review. The top reason for contractual review was for dental services.

Decisions by the IRO in favor of the consumer are binding on the insurer, while consumers retain the right to file private lawsuits even if the IRO decision is not in their favor. Consumers do not bear the cost of an external or contractual review. Under the statute, the review must be completed in 30 days, and expedited reviews involving serious health issues must be completed within seven days.

The Ohio Department of Insurance has created an on-line toolkit on its web site at http://insurance.ohio.gov/Consumer/Pages/IROInfo.aspx to help consumers and medical providers understand the health coverage claim denial appeal process and to make an external appeal after their insurer’s internal appeal process has been exhausted.

The Ohio Patient Protection Act report is available on the Department’s Web site at www.insurance.ohio.gov.