Six Independent Review Organizations Rule with Insurers in 80 to 89% of Cases

IMPORTANT: If you’ve had serious problems with Molina, please fill out this short survey to help me gather information about the company’s harms. You can read more about this below.

When my new insurance with Molina Healthcare began on January 1st, I lost coverage for my primary care doctor of nine years and the in network mental health counselor from my 2018 insurer.

You might think addressing this with your insurance company would be easy, but it’s not. And you might think the state’s Office of the Insurance Commissioner (OIC) is there to advocate for you, but it’s not either.

Instead, OIC approved Molina combining my two separate appeals to be ruled on by just one Independent Review Organization (IRO), Met Solutions, the worst one. The firm ruled with insurers 88.7% of the time in 2018.

Worse yet, OIC allowed this firm’s attorney to decide the issue as a contract case. No one with medical training ever reviewed my medical records or the now six letters from doctors and specialists arguing on my behalf. My care has been disrupted for six months and counting.

Kreidler's OIC allowed an attorney to decide medical issues and perform the independent review.

The outcome of health insurance appeals in Washington state, is partly based in law, partly based on luck, primarily based on profit and largely rigged.

Before I present the evidence, I want to tell you why this matters to me and why it may matter to you one day or to people you care about.

I Have a Brain Tumor

Harry Potter Scar

In 2015, I was diagnosed with a brain tumor and had a craniotomy and radiation. My tumor is stable but my care is complicated and there are a variety of evolving health issues that must be measured and managed. At times, just managing my care is exhausting.

If you’re healthy, disruption to your healthcare and providers isn’t a serious issue. But, for those of us with major health issues, the disruption has severe impacts on the quality of care and of our lives.

Frankly, there’s absolutely no medical basis to require patients to switch care providers each calendar year, and yet that’s how our system often works.

My doctor, the one Obama promised me I could keep, guided me in the search which led to the discovery of my brain tumor. She’s who the radiologist called from the MRI facility late on Friday April 3rd, 2015 for permission to share my diagnosis with me before the weekend. And, she’s the one that visited me in the hospital after my craniotomy. She’s the one that knows almost every detail of my treatment over the past five years.

As for my counselor, the one I worked with in the past was out of network. It took a lot of calls to find a Seattle counselor taking patients last year because the networks are essentially full. Fortunately, I found one I trusted and began working with her only to have coverage for her terminated a few months later when insurance changed over.

Washington state doesn’t require private insurance companies to offer plans in the public marketplace. So, we only have four insurance providers available to individuals, entrepreneurs and the unemployed. I chose the only plan that covered my neurosurgeon, endocrinologist and several other -ologists. All the choices were bad and there wasn’t a better choice.

How the Health Insurance Appeal Process Works

With the Affordable Care Act (the ACA or Obamacare), you can appeal problems with your health insurance to the insurer. They respond to you with a decision, either based on the law, medical concerns, profit motives, or their legal liability — there’s variance depending on your insurer’s priorities.

You have the right to request an “external review” known as an Independent Review Organization (IRO). The insurer shares your health records with a third party organization and they are paid to make a decision based on medical and legal guidelines in the ACA. You can also submit your own documentation. The insurer pays the IRO firm to review your case and issue a decision. IROs are free for patients.

There are 16 firms that Washington State uses to perform IROs. The problem is that in 2018, seven of these firms “upheld” the insurers’ decisions in 78.5% to 88.7% of cases.

IRO firms washington state
Upheld means the IRO agreed with the insurance company’s rejection of your claim.

Prior to my research, when I’d asked Deputy Commissioner Melanie Anderson how often the IROs rule with the insurer, she answered, “Overall the metrics for IRO decisions is about 50/50.” Obviously, the truth is much worse.

In 2018, there were 1,507 independent reviews and 76.6% were upheld for the insurance company. Later, Anderson added, “That [the 50/50 claim] was a stat a colleague used in a meeting the other day.” Clearly OIC’s staff isn’t up to speed on their own data.

I used the OIC’s own reporting tools to gather data for this report.

Here are the results for IRO firms in Washington since Obamacare began:

Six IRO firms upheld insurance decisions in more than 78.7% of cases

Three IRO firms decide with insurers in only 55.6% to 65.4% of cases and six firms decide with insurers between 78.7% and 84.8% of the time. There is no innocent statistical explanation that explains this bizarre distribution.

Either some IRO firms are incompetent and rule with patients more frequently or there is a group of providers that are strictly doing business to maintain insurance company profits.

The IRO Firm Rotation System

When you file a request for an external review, the OIC rotates to the next IRO firm from the group of sixteen based on your health insurance. Each insurance plan has its own rotation.

Despite these horrible statistics, the OIC’s Market Conduct Examiner Chris Pattison reports, “From 2017 through 2019, No IRO’s have been removed from the rotational registry.”

To have any chance to win your IRO, it can’t be assigned to one of the worst seven which rejected claims at an average rate of 84.2% last year. To have the best chance to win your IRO, you have to be lucky enough to have IMX Medical Management Services come up in rotation which sides with insurers only 55.6% of the time, 30% less frequently than corrupt firms.

Contractual Disputes are a Sure Thing for Insurers

Again, staffers at OIC decided that it was fine for Molina to combine both my complaints for adjudication by the very worst firm, Medical Evaluators of Texas (MET). It’s the firm that decided with health insurance companies 88.7% of the time last year. But, by allowing MET to have a lawyer decide the case as if the medical concerns I had raised were contractual concerns … the OIC is actively participating in insurance fraud, the very harm it claims to protect consumers against.

Of all types of disputes, contractual disputes are decided for insurers at the highest rate, 86.8%:

contractual disputes are decided for insurers at the highest rate, 86.8%

The IRO process puts in place these layers which make it almost impossible for you to win appeals against insurance companies and the OIC stands guard for them.

In my case, I had no say in my claims being combined. I had no say in my claims being assigned to an IRO firm so corrupt that it shouldn’t be allowed to continue operating. And, my doctors and I had no say in the decision to treat my medical disputes as legal issues. Finally, there’s even more to this that I’m not sharing today.

The outcomes of external reviews do vary somewhat based on your insurance company:

Lifewise, Kaiser and Premera patients tend to lose IRO fights 78.9% to 87.1% of the time

For example, Lifewise, Kaiser and Premera patients tend to lose IRO fights 78.9% to 87.1% of the time whereas Cambia patients lose only 68.4% of the time. This actually may indicate in part that Lifewise, Kaiser and Premera take first level appeals more seriously than Cambia’s Regence, Bridgespan and Asuris plans. When insurers follow the law and respect patients medical rights and safety, the external reviews become more cut and dry.

While this is a possible explanation for different IRO outcomes between insurers, the reason IRO firms’ statistics differ is because of their immorality and profit motives. All IRO cases of all different kinds are rotating equally amongst the firms, so they should all have similar statistical profiles, but they don’t.

The Office of the Insurance Commissioner is Complicit

My experience with the Office of the Insurance Commissioner this year has been that the department is largely complicit, working with the insurance companies, blocking my attempts to clarify medical issues and review key facts. Although the OIC recently fined Molina $600,000 for a variety of offenses and made it refund patients, it’s hard to imagine the pain these individuals and they’re families experienced last year fighting Molina in contrast to the ease with which Molina can budget for such fines.

A senior physician said to me recently of the Office of the Insurance Commissioner, “They’re horrible. They don’t do anything.” That’s been my experience as well. And, I will write more about the department’s operational failures in the near future.

What’s the Status of My Care?

In my search for an in network primary care doctor, the University of Washington’s Neighborhood Clinic said my case is too complex for them to manage and sent me to the UW Internal Medicine group. Of the ten doctors it was suggested that I schedule with, none are available for new patient appointments. In fact, there are no staff physicians taking on long term patients currently, only transitory medical residents.

As for mental health care, in Molina’s network, there are 432 mental health care providers in their network within five miles of me. Zero are taking new adult patients for traditional counseling. The directory is heavily padded with specialized providers. Not only is Molina not keeping its provider directory up to date but it’s likely in violation of the state’s Mental Health Parity Act.

The only good thing I can say about the Office of the Insurance Commissioner is how effectively it’s left me without care and without options and how well it works in concert with my private for profit health insurer to disrupt and deny my care, harming my health and well being.

Despite my $7,837 annual premium and my $2,925 deductible, I still don’t have a primary care doctor or a counselor.

Marketplace health insurance in Washington feels like a scam.

Share Your Story with Me

I am collecting complaints from people insured by Molina Healthcare. If you received a surprising bill for out of network care at an in network provider or facility or you received an anesthesia bill for surgery at Swedish, please definitely, fill out the survey.

Despite the OIC’s serious failures, I do think it’s also useful for patients to file complaints with the state, appeal bad decisions with your insurer and demand IROs, they’re free.

Finally, support the Democratic candidates in favor of universal healthcare, Bernie Sanders, Elizabeth Warren and possibly Kamala Harris.

Governor Inslee’s public option simply hires another private insurer to implement an awful public plan with tiny tiny tiny network access.

Posted by Jeff Reifman

Jeff is a technology consultant based in the Pacific Northwest.

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