NBC 5 Responds recovered tens of thousands of dollars for one Lake Forest Medical provider, but many others say they can’t afford to keep their doors open much longer without payment, as PJ Randhawa reports.
For months, medical providers who take care of active military, veterans and their families have said their bills weren't paid and, as a result, patients didn't get the care they needed.
Military health insurance in Illinois is provided by a federal military insurance provider called TriWest. It's part of a national program known as TriCare. Many medical providers who accept the insurance say their bills haven't been paid since Jan. 1, when the program underwent restructuring. TriWest previously claimed its payment delays would be resolved by the end of March.
NBC 5 Responds started investigating payment delays in February. After our report, one medical clinic in Lake Forest was able to get tens of thousands of dollars in claims paid by TriWest. Yet providers nationwide told NBC 5 Responds they are still waiting for the insurance provider to release payment to them.
Staff at 360° Wellness & Coaching in Lake Forest, which provides mental health treatment to active-duty military, veterans and their families, say they currently have 243 unpaid claims with TriWest. They say there's been no transparency or structured plan presented to resolve the balance.
While 360° Wellness & Coaching will continue offering services for the time being, other clinics are beginning to ask for payment up front or refusing to take TriWest all together.
On TikTok, a woman with PTSD told NBC 5 Responds: "My therapist who I see for PTSD has not been paid … since December. I am currently paying full price for my sessions so she can keep seeing me, pay her own bills and not go out of business."
Another woman with a chronic illness shared: "Every appointment has thousands in lab work. I need new referrals, but TriCare isn't paying doctors or approving referrals. ... I can't risk thous $$$."
Sophia Shlain, clinical director of 360° Wellness & Coaching, said TriWest also added hurdles for patients and providers when it comes to getting insurance authorizations for new or continuing treatment.
In the past, getting treatment authorized meant Slain could see a patient for up to 24 sessions. Now, Slain said, the length and frequency of treatment must be approved much more frequently, creating delays and red tape for patients who need services.
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"More than half of our patients need new authorizations by March 31st," said Shlain, who adds her clinic was told patients would need reauthorization just last week. "In order to get those authorizations, they have to do three different touch points over at the federal hospital. ... And then in addition, we need to write up a blurb explaining the medical necessity for them getting that additional authorization."
Shlainalso said TriWest hasn't explained the new changes to patients either.
"If it's taking this much time to get those authorizations and people aren't being informed about the authorizations, and now they're giving you a ridiculous deadline that's essentially a week out, that's a real issue. These people need their services. They need those services to go off smoothly," said Shlain.
In a statement, TriWest told us it expedited the review and payment of claims from 360° Wellness and Coaching after NBC 5 Responds brought the "provider's claim issues to [their] attention."
TriWest also said that it's processed more than 25,000 clams in Illinois and 3.5 million claims nationwide since January. It did not answer questions about how many outstanding claims remain in Illinois.
TriWest said it is processing more than 91 percent of claims within 30 days and that it continues "to work toward reaching our target of 98% within 30 days or less."
In response to questions about changes to authorization protocols, TriWest told us, "TriWest will accept all unexpired referrals and authorizations approved by the previous contractor through their expiration date, or June 30, whichever comes first. If the authorization expires, a new one must be completed with TriWest. Providers can also request additional authorized sessions through TriWest’s provider portal."
