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Our U. Now, why do I need prior authorization? LHI authorizes most procedures and prescriptions covered by the program, but it's up to the WTCHP which procedures and prescriptions will require prior authorization. In recent years, the list has grown.
If members' prescriptions aren't authorized when they go to the pharmacy, neither the program nor LHI will reimburse them for drugs for which they paid out of pocket. And quite a few of our members don't even have primary health insurance. First responders and survivors are also entitled to annual monitoring exams to ensure early detection of illnesses such as cancer. But several members said they haven't had the exams in years, because LHI couldn't find them providers close to home.
The first responders and survivors said it wasn't always this way. Many said their frustrations with LHI intensified in the last three years or so. Staff members said that's when things shifted from dedicated, one-on-one case management to a more metrics-driven call center structure.
Related: Nearly 3, people lost their lives on Sept. In a statement, a WTCHP spokesperson said the program can't comment about specific members' cases but "is aware of these concerns and, where appropriate, [is] working with LHI to fix the issues. LHI didn't respond to a detailed list of questions. A spokesperson said that the company is "committed to treating every individual we serve with care and compassion" and that it will "carefully review" members' concerns. Limited staffing has also worsened excessive wait times for members to get hold of someone at the company, employees said.
Over half the members NBC News spoke with estimated wait times of 30 minutes to an hour before they reach someone who might be able to assist them when they call LHI. While it is aggravating for anyone, experts say, it can be particularly harmful for people with PTSD and anxiety. It's setting them up for failure from the very beginning. Young said some members get so fed up that they either leave LHI or stop using the program altogether.
I just quit calling because nothing was being done. I had to put that energy toward LHI, instead," she said. In , the couple decided to leave LHI and start seeing one of the health program's hospitals in New York, even though it means Mike has to drive in from the outer suburbs of New Jersey for his appointments — and see the skyline he dreads every time. The two years after Maxwell's chest X-ray were "an ongoing nightmare" for Maxwell and his wife, Pat Aubert, as the couple tried to get the program to pay for approved blood tests and doctor's visits.
Aubert, 72, said she has had to step in and take charge of her husband's medical advocacy over the last few years because the lack of empathy from LHI piqued Maxwell's anxiety too much. Teresa Schlintz, a former LHI employee who was with the company for four years and used to be Maxwell's case manager, said: "I realized Kevin's health was hurting because he was in the program.
The promises kept getting broken one after another, and they were groveling for benefits. Schlintz was terminated this year on the grounds that her return date from mental health leave was indefinite. As the couple fielded calls from debt collectors, they said, a representative of LHI told them that their X-ray claim had been rejected because of a coding error.
Eventually the provider wrote off the bill as a bad debt. Eight other members said they have dealt with collection agencies or providers threatening to send bills to collection agencies over services they thought the program was covering.
A spokesperson for the WTCHP said that providers sometimes bill members by mistake and that "while there are things [LHI] can do to educate the providers
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