Ohioans Recover $900,000 From Denied Health Claims

The Ohio Department of Insurance's annual Ohio Patient Protection Act report shows Ohioans saved more than $900,000 in 2009 from health care claim denial appeals. 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 allows Ohioans to request an independent, external review for denial, reduction, or termination of certain health care services by their health insurer. 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.