The Insurance Intelligencer
4/19/09

The Independent Review: Don't count on it

Forty-one out of the fifty states mandate an independent review of health insurance denials. Sounds like a good thing, yes? Even people who should know better say, "It's independent, and that's got to be better, doesn't it?"
No, no, and no. As soon as you find out the purpose of these independent reviews, who does them, and what they consist of ... you will do everything in your power to never, ever go there.


Purpose of the independent review

The independent review comes after you have exhausted all of your appeal options with the insurance company.

Before independent reviews, insurance companies couldn't get rid of troublesome patients who needed lifesaving treatments, and who wouldn't take "no" for an answer. These pesky individuals kept calling and writing letters. Sometimes they even appeared in the media and hired lawyers to bother the insurers into letting them have the treatments they needed.
How to put an end to all this trouble? After two or three denials, send them to an Independent Review. It is now written into your contract with the insurer that, once your case goes to Independent Review, you have no more recourse with the insurance company.

Voila! Demanding insured people are out of our hair, they cannot come knocking on our door ever again.


Who does these reviews?

Why the "Independent Review Organizations," of course. Sounds very official, substantial, professional, doesn't it? Let's see who they really are.
I rarely get involved with independent reviews, because I generally win appeals on the first go-round.

However, my latest case had already been denied twice. The insurer had washed their hands of it, and it was on its way to an Independent Review Organization (IRO) called "Speciality Independent Reviews."

The treatment in question was the same cancer treatment that I once had: an incredibly complex and extensive abdominal surgery, and heated intraperitoneal chemotherapy. One of my main arguments in the appeal was that the doctors who denied this treatment the first two times had never performed it, knew nothing about it, and were not qualified to render an opinion on it.

Further, I proved that having a reviewer who did not regularly and currently perform the treatment in question was illegal according to the state's insurance statutes.

The insurer paid no attention to me, and the case went on to Independent Review.

"Who are these reviewers?" I asked, "Are they going to be any more qualified than the Family Practice physician and the pharmacist who denied it the first two times?

What I found out was not surprising to me, since I have hacked my way through so much insurance company propaganda. It was, however, deeply disappointing.


IROs are "certified"

Insurers and Insurance Commissioners refer to these reviewers as "Certified Independent Review Organizations." Propaganda, slightly professional-sounding, signifying nothing.

If you are any kind of a professional, you know that "certified" is the lowest requirement on the totem pole. "Certified" usually means that you paid $150, and got on a list. In terms of qualifications, it means nothing.


What is an IRO?

Is it a group of highly qualified doctors of all specialities who will use all due diligence to take a fresh and unbiased look at your case?

Remember our case of the complex cancer surgery with intraperitoneal chemotherapy? The IRO that was going to render the opinion on this case was a chiropractor with a post office box in Texas.

There are no doctors at the IRO. As a matter of fact, whoever is at the IRO knows so little about these cancer treatments that are being denied, that they wouldn't know enough to know who to refer the case to.

This IRO was in no way an "organization." It was a P.O. box.


To whom are they accountable?

These IROs are not regulated by nor accountable to anybody.

You as the patient don't get to know who reviewed your case, you have no input, you have no leverage, you have no recourse. Once the IRO has rendered their opinion, your only option is a lawsuit.

From what I can tell, the only way to win a lawsuit against a health insurer is to either have the wrong leg cut off, or be dead. Denial of care cases don't do well in courts, because you haven't let the insurer damage you yet. Further, no court moves fast enough to save your life.

Independent Review Organizations publish no statistics on how many cases they approve or deny. "Specialty Independent Reviews" could deny every single one of the cases that came their way, and no one would ever know about it.


Word to the wise: Win your case while it is still in hands of the insurance company. Independent reviews are nothing but a thin veneer of "process," meant to get everybody who is accountable off the hook.