The Ohio Department of Insurance Releases 2006 data on healthcare claim denial reviews.

Ohio’s Patient Protection Act, which allows consumers to appeal health care claim denials to an Independent Review Organization (IRO), saved Ohioans nearly $2.4 in 2006, the ODI has announced. The Department is mandated to compile and annually publish information regarding the outcomes of the reviews. In 2006, a total of 156 IRO reviews were conducted for numerous types of services with the majority for surgery and hospitalization. The Department reviewed a total of 190 contractual cases. The top reason for review was for out-of-network issues. In many cases, medical necessity decisions were also reviewed. The report is reorganized this year in an effort to be more transparent and consumer oriented.

The Patient Protection Act allows consumers who have been previously denied coverage for a health insurance claim or have had coverage reduced or terminated, the right to request an IRO to review the case. Under the statute, the review must be completed in 30 days, and expedited reviews involving serious health issues must be completed within seven days. External reviews are assigned to one of nine randomly selected organizations accredited by the Department. In cases where the dispute involves contractual matters such as coverage limits or definitions of coverage, the Department conducts the review internally. 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. 

For additional information about Ohio's Patient Protection Act, please call the Department's consumer hotline at 1-800-686-1578. For a complete copy of the report go to: http://www.ohioinsurance.gov/Legal/Reports/2006_HB4_Governor_Final.pdf