“External Review” and “Independent Review” – Are They Different?
There can be a BIG DIFFERENCE between an “external” review and an “independent review.”
WHY IS THAT DIFFERENCE SO IMPORTANT?
Many times a bariatric surgery appeal is sent by your insurance plan to an “external peer reviewer” who often comes back with another denial. Then they write you or your surgeon a letter saying “this matter was reviewed by an external peer specialist with expertise in bariatric medicine…” or something similar.
Remember that is part of the insurer’s “internal” appeal process so it’s controlled by them. You can imagine whose side that “external” reviewer is on, can’t you?
WHAT SHOULD NOT HAPPEN?
Patients or their doctors’ office often just give up if this “external” reviewer upholds the insurance company denial. They mistakenly think they’ve got no other option to fight. That’s not true.
WHAT SHOULD HAPPEN?
Make sure you get your appeal reviewed by a truly INDEPENDENT REVIEW ORGANIZATION (IRO) and have your case decided by someone who is not controlled by the insurance company or bound by the insurer’s rules and medical policy.
AND WHAT CAN HAPPEN THEN?
We get a WONDERFUL Friday morning email from a lovely person who just found out we helped them get their approval:
I WAS APPPPPPPPPPROVED!!!!!!!! The IRO overturned the denial!!!!!!!!!!!!!!!!!!!! I just got home from work and there was a letter from UPS from them. I’m a big baby right now over this. I’m going to run out of tissues, lol. I cannot thank you ALL enough. WOW!!!!”