Posted on 07/27/2007 4:19:04 AM PDT by Tennessee_Bob
I'm in a business that I hate, working on the front line between patients and upper management, and I'm considered to be damned good at what I do. I'm a senior customer service representative for a pharmacy benefits manager. I'm praying though, that the job interview I have this morning will get me out of the job I'm currently in, and back into the fairly sterile world of IT.
It's not my job to deny benefits, no matter what the patients might think. My job is to explain the denials, explain how the benefits plan works, and to help the patient understand why their benefits plan is denying their requests, no matter how f###ed up the reasoning is. It’s also my job to keep the patient from wanting to escalate beyond me, on to upper management, and in a lot of cases, explain to upper management why we need to make exceptions in what we’re doing for a patient.
It’s like this…upper management sees dollar signs, and interacts with the client – huge (and not so huge) contracts to manage medication for companies and groups of every size. They don’t deal with the individual patients like we do. They deal with dollar signs, and dollar signs are pretty convincing to them. If they were on the front lines with us, things might be a little different.
I can’t say that I’ve seen it all – but I can say that I have seen an awful lot of it. I have seen plans that don’t deny anything to their patients – if you can convince your doctor to write you an RX for six hundred Viagra for a 30 day supply, they’ll allow you to fill it for a twenty dollar co-pay. Is your doctor convinced that you really need to take twenty-four 80MG Oxycontins a day – have him write a letter, and this one plan will approve it. Then again, I have seen plans make some of the worst denials in the world. An eight year old girl’s mother calls in on a Friday evening, after normal business hours, because she’s trying to refill her daughter’s asthma medication for the third time at a pharmacy down the street. The fill is denied, because now they only allow two fills at retail, and then you have to use mail service. This is a new policy, and the letters only went out a week ago. If I e-mail the plan administrator with a request for an override – they’re going to deny it, because the plan says only two fills at retail. See – they’re seeing the dollar signs being held up by the plan – they’re not dealing with a mother whose child is going to get ill over the next two or three weeks while she gets a script from the doctor, mails it in, and waits for us to fill it.
What do you do as a customer service representative faced with this situation? Simple – you call me on the phone, and transfer mom to me. She tells me what’s going on – and I look at what’s happened. Half the letters have gone to the wrong address, because the patient’s haven’t updated their address lately at their benefits office. Of the fifty percent that received the letter, half of them round file it, because who ever reads stuff coming from the benefits company? So there’s a strong possibility that mom never saw the letter. Or maybe it went to an ex-husband who didn’t share the information with her. But I don’t see that. What I do see is an eight year old girl who needs her medication. And I enter the override, and allow her to fill the medication – because it’s the right thing to do. I enter the override, and educate mom on what she needs to do in the future – after all, while she’s paying twenty dollars for the medication at the local pharmacy for a 30 day supply, she can get a 90 day supply at mail service for only forty dollars. And come Monday, the plan administrator sends me a nasty e-mail, asking why I did what I did – not seeing the eight year old girl who needed her asthma medication, but only seeing the dollar signs. I get told that if I do something like that again, it might affect my paycheck. But I’ll do it again, because if I don’t, it will infect my soul.
Want to know why you pay so much for health/pharmacy benefits? Ask the hemophiliac down the street how much they pay for their clotting factor. They might pay a co-pay of thirty dollars for a thirty day supply. Ask them how much their plan pays for it though. I’ve seen pharmacies that submit usual and customary costs (what you would pay if you bought it without benefits) of $750,000 for a thirty day supply of the stuff, and a contract cost (what the plan and the pharmacy have agreed on) of $350,000, and a co-pay of thirty dollars. The remaining $349,970 has to come from somewhere, and it comes from your premiums. Ask the cancer patient how much they're paying for their meds. For that matter, ask anyone you know how much they're paying, as opposed to how much the plan is paying for them.
I explain that quite often. Yes – I know – you had to pay fifty dollars for that medication. I understand that that is a high co-pay, and I know that you pay your premiums every month. Did you look at the Explanation of Benefits that showed that while you paid thirty dollars, your plan paid seven hundred dollars for the medication? And that they paid, in total on this order, over three thousand dollars for your medication – while you paid a total of one hundred and fifty dollars for your co-pay? No sir – I don’t know how people without insurance get along – I guess they just do what they can.
Good luck with the interview.
That was very informative! Best wishes for your future employment!
I will be thinking of you Bob!
The first person they yell at is me behind the pharmacy counter. Then I call you because they never believe me, as though I am making it up that they can’t get the 3rd refill at retail. Some eventually apologize for taking it out on me. Most don’t. It’s an ugly, ugly job. Sometimes it’s hard to feel bad for the poor little girl who needs her inhaler while the nasty mother is cursing at me, like I make up the rules.
Best of luck to you! I’m sure you’ve always done the best you could where you are, and I appreciate you.
Thank you folks for reading and keeping me in mind. I’m back from the interview, and getting ready to head to work.
Based on the questions and answers and the responses - I think I got the job. I called the VP who will be running the call center after the interview, and he let me know that they would be calling me back later today to discuss it further. This is a small technical company that has been wanting to bring me in for awhile, but only now got the slot available. Hopefully, within a week or so, I’ll be providing tech support to DHS-ICE.
I’ll let y’all know more when I hear more.
Cool, keep us posted
Thank you for what you do, Bob. It sounds like a thankless job, but you’ve got mine.
And I know, ...... KNOW, you will have the perfect job at the perfect time.
Just got the call - I start my new job doing tech support for DHS/ICE on 08/18/2007. I’m back in the IT field! Thank you all for your support :)
Congratulations! I’m very happy for you, and I hope the new job goes great!
All RIGHT Bob. You just put a smile on this face. Congratulations!
Cool, knock ‘em dead!
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