Improving Transparency

NoHLA Report Recommends Improved Database for Health Insurance Appeals

Northwest Health Law Advocates (NoHLA) is pleased to announce the release of its “Report and Recommendations on Washington State’s Independent Review System.” The report recommends improvements in the system for collecting, analyzing, and making publicly available the decisions issued by Independent Review Organizations. NoHLA’s proposals would benefit consumers by improving transparency and accountability.

Independent Review Organizations (IROs) are neutral reviewers of health insurance companies’ denials of coverage after a person has reached the end of their insurer’s internal appeal process. IROs issue written decisions on whether the insurer’s determination was correct, but currently the decisions are not collected and there is no usable database of these decisions. As a result, consumers who appeal denials are not able to find or use past IRO decisions.

An effort to create more transparency is already underway: The Office of the Insurance Commissioner is developing a searchable database of IRO decisions to be launched in 2015-16. And a bill introduced today in the Washington Legislature by Representative Jim Moeller, House Bill 1956, would give the OIC more authority to improve the system as suggested by the report.

A well-designed database could significantly benefit consumers and the public:

  • The collection of information about IRO decisions would be more uniform and accessible.

  • A person appealing a benefit denial would be able to learn of previous IRO decisions on similar claims. With this information, consumers can more effectively prepare and present their appeals to the IRO, which is an impartial decisionmaker.

  • The decisions can contain required elements, ensuring higher quality.

  • Data and trends from the decisions would enable OIC to enforce and regulate carriers when patterns of improper denials emerge.

Those involved in the IRO program agree that an improved, transparent system is long overdue. As one advocate said, when told about OIC’s database, “A searchable database sounds too good to be true.” The database, along with other reform, would have great value for patients, particularly the majority who must represent themselves in the appeals process.

Summary of NoHLA’s Recommendations

A. Consolidate IRO reporting, data collection, and regulation in OIC

The Department of Health currently handles most aspects of the IRO system, but the OIC is the agency regulating health carriers. A transfer of responsibility to OIC would ensure appropriate oversight and analysis of the information collected from IROs.

B. Continue developing a strong, transparent independent review decision database

OIC’s searchable database of IRO decisions should include sortable fields such as health condition, procedure, and carrier name. Personal information would be removed. The search function should allow consumersto learn about IRO decisions regarding similar issues to their own, for a specified carrier. OIC would be able to identify carriers that need monitoring or enforcement.

C. Improve the quality of IRO decision reporting

Currently, IRO decisions vary in content and are not standardized. In conjunction with developing the new database, OIC should create a form for IROs to use in issuing decisions.

The full report is available here