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Denial reviews: Some more than orders

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One of the usually-obscure state agency rules changes in Idaho last week concerns something that could be of life-altering concern to some Idahoans: The rules covering external review of denials, policies and other details of health insurance provider consumer relations. The changes, many coming at the request of insurers, provide for reviews “to include denials based on appropriateness, health care setting, level of care and effectiveness.”

The reviews mean that when a policy holder has a complaint, an external review can be undertaken to sort out the situation, rather than the highly expensive resort to a lawsuit. This grows out of federal health care law; the general provisions were put in place in Idaho last year, covering policies issue or renewed since the start of 2010. State generally have been doing this; Idaho is among the states which have received a federal approval for its program, run through the state Department of Insurance.

Considering the numbers of complaints people have had about health insurance, one might expect this to be a very busy area. But in Idaho, not so much. Eileen Mundorff, who works on the program, said that in the first calendar year of the program (2010), the department received 13 requests for external review; of those, two company denials were overturned by independent review organizations. So far in 2011 the department has received 22 external review requests, and as of September 8, an estimated $284,821 was recovered for policyholders. Idaho has been approved by the federal government as meeting requirements for external reviews.

Not a lot of requests, though the money recovered when inquiries are undertaken can clearly be substantial.

Oregon, whose insurance division has been tracking all insurance complaints though differently (more comprehensively and for more years) reports in 2010 that there were 912 total complaints and 555 “confirmed complaints.” (Of the 912, Regence BlueCross BlueShield accounted for 162, which may be one reason Northwest stat regulators had a recent sit-down with the firm in Salem recently.)

Similarly, the Washington insurance commissioner’s office reports that for 2010 (as in Oregon, the most recent figures available) health insurance complaints totaled 562 (of which the Washington and Oregon Regence organizations accounted for more than half).

Are these somehow apple and orange comparisons? If not, what accounts for the difference in numbers of complaints? Is there a reason Idahoans are much less inclined to report health insurance complaints?

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One Comment

  1. ewmundorff ewmundorff September 13, 2011

    Randy, this is Eileen Mundorff, and yes, this is apples v. oranges. We discussed external review #s, not total complaint numbers, when we talked. In 2010, the Idaho Department of Insurance received 900 written complaints on all types of insurance, and recovered $2,992,056 for Idaho consumers. We receive external review requests only for health insurance when an insured has exhausted the insurer’s appeal process or has an urgent care request denied. We can then refer those denials to an independent review organization to determine if the health carrier made a decision in line with standard national medical guidelines.

    Oregon and Washington also allow for external review requests and track that information separately. You may want to contact those offices and ask about their #s for external reviews only.

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