FOR IMMEDIATE RELEASE
January 28, 2009
Contact: Jason Moon 517-335-1700

LANSING – The Office of Financial and Insurance Regulation (OFIR) today reminded Michigan consumers that under the Patient's Right to Independent Review Act (PRIRA) of 2000 they have the right to appeal the denial of health benefit claims, reduction in benefits or a refusal to provide health care coverage.

"Most people aren't aware that they have a legal right to an appeal without having to hire an attorney or go to court," OFIR Commissioner Ken Ross said. "This is a powerful tool for consumers faced with a claim denial which could potentially cost them hundreds of thousands of dollars."

In 2008, one third of all consumers who exercised this right won their appeal or had their appeal resolved before a decision was issued. Of the 313 appeals filed with OFIR, 48 were decided in the consumer's favor and 56 were resolved between the consumer and their health carrier.

2008 PRIRA reviews included issues involving insurance coverage, medical necessity, out-of network services, amounts paid and experimental procedures. PRIRA appeals occur after a consumer exhausts their right to an internal appeal filed with their health carrier and a formal meeting between the carrier and the consumer.

In 2000, the State Legislature determined that the importance of health care claims warranted a special, expedited procedure to ensure that individuals entitled to benefits are paid swiftly. PRIRA reviews are conducted on claim denials by commercial insurers, health maintenance organizations, and Blue Cross Blue Shield Michigan. In general, adverse determinations made by non-governmental self funded plans are not subject to review under the PRIRA statute.

Reviews under these statutes determine whether an adverse determination by a health plan is consistent with the language of the policy or certificate of coverage under which an individual received health care benefits. The review also determines whether the policy provisions are consistent with state law.

In some cases, the adverse determinations are based on medical questions. There, the medical information is submitted to an independent medical review organization (IRO) where it is analyzed by a physician specializing in the relevant medical field. The IRO analysis and recommendation is then submitted to OFIR and made a part of the Commissioner's decision.

For a list of PRIRA cases visit: http://www.michigan.gov/dleg/0,1607,7-154-10555_20594_20596---,00.html

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