Texans Appeal Few Cases to Independent Review Organizations

By Ronald L. Scott
RScott@central.uh.edu

When Texas recently passed legislation allowing patients to appeal their health plansí determination that proposed treatment is not "medically necessary," the Texas Department of Insurance expected 4,400 appeals in the first year. However, the Houston Chronicle reported that, as of March 19, 1998, only sixteen appeals have been filed.

The Texas statute provides that such appeals are decided by Independent Review Organizations (IROs). An IRO is a state-licensed organization that conducts an independent, unbiased review of a health care planís decision to deny care where a patient (or the patientís physician) believes such care is medically necessary. The Texas Department of Insurance licenses IROs after an application process that insures the IRO has the necessary expertise and independence to conduct such reviews.

A patient or anyone acting on the patientís behalf (e.g., a physician) may initiate a request for IRO review. The statute provides that when an HMO or insurer denies treatment requested by a patient or the patientís physician, the health plan is required to advise the patient of the right to appeal the determination and to send the patient forms and other information necessary for an IRO review. The health plan is required to pay for the costs of the review. If an IRO agrees that requested treatment is medically necessary, the health plan must pay for such care. Regardless of its decision, the IRO must furnish the patient with a notice of its decision that includes: (1) the clinical basis for the IROís decision; (2) a description of any screening guidelines used in making the decision; (3) qualifications of the IRO personnel who reviewed the case; and (4) certification that the IRO has no "conflict of interest" with the health plan which could cast doubt on the IROís independence.

The IRO process is intended to give patients a quick and easy way to resolve denial of care disputes without the expense of going to court or dealing with corporate bureaucracy. Patients have won in six of the fourteen cases decided by IROs (two cases are pending). In one case, the IRO ruled that a patient was entitled to a liver transplant that had been denied by the patientís insurer. In another case, the IRO decided that a patient should receive inpatient treatment for chemical dependency.

03/19/98