An Independent Medical Review, or IMR, is generally used by an insured individual when their health insurance company denies a medical treatment that it deems to be unnecessary even though it is still covered by their policy. IMR's are performed by doctors who review these medical decisions made by an insurance company. Most States administer their own Independent Medical Review programs, and there are many private medical companies who offer this service and who are registered with their State as meeting the strict guidelines set forth by applicable legislation.
Health insurance companies have always had their own internal review process for determining whether a medical procedure is necessary in a given case. It should be noted, however, that these health insurance companies are also driven by profit and financial motivations, so there is an inherent bias that has lead to the need for the Independent Medical Review process. This insures that medical decisions are made in the interest of the patients health and are not influenced by monetary gain.
The IMR process is not about determining health insurance coverage issues. An individual must be covered for the medical services in question. If they are covered for a particular service but it has been denied as not being necessary, they must first use the internal review process already available with the insurance company. Only after these efforts have been exhausted can the patient apply for an Independent Medical Review. If it has been at least 30 days since filing an internal review or grievance with an insurance company and they have not responded or have maintained their denial of a medical service, the insured individual can apply for an external review. Generally this falls into the following categories but may vary according to which State a person lives in:
1. A covered treatment was denied and considered unnecessary.
2. A claim was denied for emergency medical care.
2. A claim was denied for experimental therapies.
If a patient needs a more immediate medical service and a doctor certifies that fact, an IMR can be initiated before the 30 days referred to above. The internal review process may be waived if a person is at risk to losing life, limb, bodily functions, or results in severe pain.
Many medical decisions made by insurance companies have, in fact, been overruled by the IMR process. Approximately half of the IMR cases result in rulings favorable to the patient. That statistic will also vary considerably from State to State because some States are more sympathetic to the cause of the patient than others.
The Independent Medical Review process is not available to everyone. A few States do not have IMR laws or programs to administer this review process. Also, IMR's do not apply to self insured plans. These are plans paid for directly by the employer and not through an insurance company. Self insured plans have their own regulations and are exempt from State review programs. An individual in a self insured plan must use the internal grievance process for that plan or take legal action to overturn a disputed decision. There are currently no Federal laws or guidelines that cover all plans with an external review process. Medicare/Medicaid patients have their own external review process.
For those who do have access to the Independent Medical Review process, the application process is readily available. Insurance companies are required by law to provide the application with their denial letter. Applying for an IMR does not prevent a person from taking further legal action against an insurance company, but not using the IMR process may limit those legal actions. It is always best to consult with your own doctors and attorneys before making these decisions.
