Whether or not medical treatment is covered by insurance can literally be the difference between life and death. Since 2001, California law has given consumers the right to have certain kinds of medical insurance claim denials independently reviewed. These reviews are called “Independent Medical Reviews” or IMRs.
The Sacramento Bee reports that thousands of IMRs have been done in the few years they have been available and that state officials are trying to get information about the IMR option out to the public. Detailed information is available online and by contacting the agencies involved. You may be required to exhaust the internal appeal or review system with the insurer first.
IMRs are not for typical coverage disputes, policy-language interpretation or bad faith insurance denial claims, but rather apply to a narrow class. The three specific situations that each trigger the right to IMRs in California are:
- The insurance company says the treatment is not medically necessary.
- The insurance company says the treatment is experimental, unproven or investigational.
- The insurance company denies a claim for emergency or urgent medical service.
IMRs can be requested for both insurance denials after treatment has occurred or for denials of preauthorizations.
Two state agencies perform the IMRs: the California Department of Insurance for individual policy holders and the Department of Managed Health Care for members of HMOs and managed care plans. Members of self-insured plans and people on Medicare are not eligible for IMRs, nor are Medi-Cal fee-for-service members (as opposed to those on managed care).
The reviews are performed by medical professionals who are independent of the parties involved. If the IMR is decided in favor of the patient, the insurance company must cover the treatment.
The Sacramento Bee says that for 2011, the DMHC performed 1,624 IMRs of which 640 claim denials were reversed, 294 were approved by the insurers in a change of action before the IMRs were complete and 690 denials were affirmed. Those seem to be odds in favor of pursuing an IMR if it is available to you.
A patient may authorize another person to help them with the IMR plus a medical professional may also assist. Be careful to meet filing deadlines; extensions are only available in certain special circumstances.
Most IMRs take only up to 30 days and there are provisions for expedited review in emergencies. IMR costs are covered by insurers, not consumers.
The question whether to ask for an IMR may be important from a legal standpoint as far as whether future legal action may be waived by foregoing an IMR, so it is extremely important to discuss the decision with an experienced California health care attorney to understand your rights and options.