You’ve got to like talking to people because you’re going to talk to a lot of them.
Lori V.
Account Support Representative
Going back a little bit, I have two kids and I was a single mom for most of the time. We were in Washington state and I was working as a sales and marketing director at one of the Brookdale Senior Livings, a memory care facility. We had the most successful community in western Washington, so it was going really well. This has been gosh, 11 or 12 years ago and that was when the economy was starting to not do so well. My son had graduated and he had moved back to LA to go to film school and my daughter and I were alone, she was going into her senior year of high school. She really missed her brother, and I did as well, and he wanted us to move back so we packed up everything and moved back to Southern California. My position I was at, they had me travelling to different problem communities where their census was down and they ended up sticking me in Arizona and I had to fly back and forth and basically live there and come back on weekends. I didn’t like that, of course, because my daughter’s a senior in high school here. And then the company went down; well, not down, but they weren’t doing well at all so they laid me off and between that and the current position I’m in, I was just scraping for anything. I took a job at CVS working pretty much minimum wage, and then worked at a tile company… just whatever I could grab to survive.
Prior to the senior living, I was working at the Tacoma News Tribune and then on to the Seattle Times as inside sales and advertising rep and did really well back then. Won sales person of the year with the News Tribune. Lots of bonuses; it was so different! Every Friday there would be little contests and handing out cash. But I could see the newspaper business was dying quickly. That was about the time that Career Builder and all those came along and I was in employment advertising. But I was really good on the phones. I didn’t like outside sales. I don’t know, it’s just easier for me to talk on the phone and convey what I need to get through.
I do pharmacy benefit management for workers comp and also auto injuries. Workers comp entitles being a liaison between the claims adjusters and their claimants, the pharmacies and the doctors writing the prescriptions. Any injury has a specific formulary set in whatever state they’re in. If the medications aren’t on that formulary, they’ll require authorizations from the claims adjusters. So the process is the claimant will go to the doctor, he’ll write out the scripts. In a perfect world, the pharmacy will receive the prescriptions. Anything that’s through the formulary, they can get right away, it’s paid for 100%. If it requires an authorization from the claims adjuster or a utilization review or a nurse case manager, we send it and the request.
For injury claims, we have formularies that are set depending on the jurisdiction of the injury and which body part was injured. California and New York are the toughest as far as getting authorizations for medications off the formulary. We get updates all the time that things are changing. That’s also a challenge for all of our programmers to keep up. Then there’s a QA team that’s double-checking things. They’re making a lot of changes, trying to make it more fluid and flow a little smoother, trying to get rid of the pharmacies having to call. The big chains are the problems because they’re overworked and understaffed and now they’re doing vaccinations on top of it all. Hopefully soon when they save something that needs an authorization it’ll automatically go into a queue for us that we can pull out so we don’t have to rely on those phone calls that don’t happen 75% of the time.
For example, the pharmacies don’t call in the authorization request they need. Or when they tell the claimant, “Oh, no, we’re waiting on the insurance.” You haven’t alerted the insurance! We have our system and then the adjudication system which is what we communicate through with the pharmacies, and I’m able to pull up their information and go, “Oh, they’ve had that for five days and we had no idea.” So I go, “Do this moving forward but for right now I’m going to send this to the claims adjuster right away and I’ll call you back, I’m going to also back it up with calling them.” A lot of times I can get through to the claims adjusters. Just expediting things – the pharmacy failed to call in, it’s been pending for five days, they really need it. So you’re able to do that, whereas if you just send an e-mail, it’s at the bottom of the list and there’s no urgency. Just taking the extra step to do whatever you can to get them this medication that they’ve been waiting for. That’s what I tell the patients too, “I know it is an extra step but do your due diligence and call us, that way it’s not sitting there and you don’t know what’s going on, you know for sure that it’s taken care of because you let us know and we can proceed to do what we need to do to get your prescriptions approved.” And they’re like, “Thank you for doing that.” You make a lot of friends and then the people you can’t help, it’s kind of heartbreaking. After you’ve had five back to back calls like that, it’s mentally exhausting.
A pharmacy, if they get a rejection, they never read the screens, which is our biggest frustration. They’ll just say, “Oh. It was denied.” No, it’s not denied, read the screen. It says “rejected for whatever reason, start preauthorization request, please call” and then our phone number, in red... almost flashing! A lot of times they don’t follow through. So if nobody calls us, we don’t know they need this medication and it can sit there forever until somebody takes action. A lot of times, it’ll be the claimants calling, going “Where’s my…?” They’re upset, they’ve been waiting already for maybe four or five days. I just preach to the claimants, “Please, whenever you know you’re going to need a prescription, please call us first. We’re open 7 days a week, holidays included. Please call and let us know so we’re aware and we can do what we need to do to get the approval from your claims adjuster.” Half of it is training claimants, and trying to school the pharmacies. Even doctors will call, making sure stuff’s going through.
When things are dire, there’s a protocol. First we send in a request for authorization on a certain medication. And it’s all done electronically. Sometimes the adjuster will come back and they’ll go, “We need a letter of medical necessity from the doctor’s office, this doesn’t make sense.” We take the brunt of a lot of it for the claims adjusters because they won’t answer their phones for claimants. And if those claimants are represented by an attorney, they absolutely won’t, they’re not allowed to.
What’s frustrating to me is when a pharmacy calls and says, “He’s waiting to be discharged, these are his discharge medications.” “Oh so he was in the hospital and we wouldn’t even have known?” “Yeah, he had surgery yesterday.” If we would have known this ahead of time, we would have changed the formulary to the surgical formulary which allows for pain medication, very limited, but enough that they don’t have to wait around for authorizations to come in.
Recently, a lot of the states are really cracking down due to the opiate crisis and a lot of other medications that are problematic. As of June 7, New York is finally putting this law into place that for anything that is not on the formulary, which includes all the pain killers, the doctor now is required to submit this paperwork to the state through the New York Workers Comp Board, on a portal and then they determine whether the state will pay for it, whether it’s approved or not. The doctors have known this was coming for two years and they’ve known they should have been weaning people off. They’ve known this was coming and a lot of them did absolutely nothing to help the claimant with alternative medication. In the meantime, letters were sent to these people, letting them know which medications they’re on that are not on the formulary and these may or may not be approved anymore and your doctor has received the same letters, you need to communicate with your doctors on plan B. It’s really fallen through the cracks and it’s become extremely stressful because these people are dependent on these medications. They’re like, “I have one left, what am I going to do?” Super frustrated, super scared about what’s going to happen and they can become very verbally abusive. I’m using as much compassion and empathy as I can, but there’s no solution that I can give them. Our hands are tied. So that’s our biggest obstacle right now. And we keep getting more and more clients, of course. We’re not properly staffed. It’s become a very stressful situation and by the end of five days, I definitely need two days to decompress. Three would be perfect!
This law was supposed to go into effect prior to COVID and then COVID broke out, so they’ve delayed it several times. And now all of a sudden they’re not available to talk to the claimants. It’s a Thursday and they’re going to be out of their medication the next day and then there’s the weekend… there’s going to be a big upswing with ER visits for these people because they’re going to go into withdrawal. And they’ll go to heroin. I know that’s an extreme, but it really isn’t. That’s what’s happening. It makes me emotional because I truly like helping people. And they’re so grateful because a lot of people they’re talking to don’t give a shit. I’m like, “Ok, hang on, I’m going to call you right back,” and they’re like, “Oh my god, thank you. What’s your name?” Then it’s a Catch-22 for me because it’s, “Lori, what’s your number, what’s your extension?” So my workload is very heavy.
You just gotta try to do the best you can and with this new New York law, I don’t know what they’re going to do, it’s just a mess. California’s almost as bad with workers comp; they also require additional paperwork and I find that once these things go into law a lot of the doctors are going to stop seeing workers comp just because there’s all that additional paperwork.
Listening skills, for sure. Some compassion and patience. The ability to articulate with doctors because they can be very arrogant. As are utilization review people, nurse case managers, anybody that’s gone through all that schooling doesn’t want to talk to somebody that isn’t communicating. We have a lot of young people on our team and their work ethics and communication skills are so badly lacking. I think the experience and the maturity is very important. You’ve got to like talking to people because you’re going to talk to a lot of them. You have to be in the right mind space and when you’re not it doesn’t work.
But then on the other side, to me it’s outrageous the way corporations are right now. I come from cost of living raises and full medical benefits and up to 6% 401(k) matches. That’s gone and the younger people don’t know any better. They just go, “Oh well…” And here I am, Norma Rae, “No, this is bullshit!” We don’t have a living wage. It’s all about making the shareholders happy. Screw the minions. They only do the job, making money for you, that’s all. It’s a bitter little pill with me.
I've been doing this for five years now and there’s a lot of turnover in my department. We’ve been working at home since a year ago March because of COVID. It’s worked out great for me but they’re having to hire so many new people because of all the new clients coming in, we don’t have the workforce to handle it. They’re hiring people as fast as they can, but I can’t imagine learning this virtually, being trained virtually. I’ll reach out to the new people because when they have questions, we use Teams to chat back and forth to whoever we need within our company. If I see somebody struggling, going, “Oh my god, how do I do this?” and if it’s something simple, I’ll be like “Do this, do this” and try and encourage them because I don’t want them to leave because I need them! And when you’re one of the most senior people, you’re routed everything. They route phone calls for anything including problems or speaking to adjusters that have issues… a lot of them I have really good relationships with.
They’re always wanting new leads on the team. Or accounting, no. Or collections, hell no. There’s lead positions, and it cracks me up because I'm a Level 2 and a lot of new people who are getting hired are Level 3s. Really? All I want is to move up to Level 3 and get paid what I should get. There was a posting, it’s probably been a year ago. “Level 4, blah blah blah.” Never mentioned it was a lead position, because they may as well say you’re one of the slave masters now. You have committed to as much overtime as needed. That means 12 hours a day. Don’t ask me to stay overtime because in the last 8 hours I’ve put out more work than somebody that is here 12 hours.
Whenever they want to know how the floor’s feeling, they come to me because I’m the mouth. I speak the truth, I’m not going to pull any punches, I’m not going to tiptoe around, because they need to know what’s real. Somebody that’s too meek to speak up, that’s not me. They know – I've been told to back off a little.
It makes it interesting because it’s nationwide. I’ll get a phone call from a frustrated New Yorker that can’t get their medication, and you get through that one and the next one is like, “Well hi, bless your heart…” you know? I’ve told them in stand-ups, “Nothing against New Yorkers, but how about less New York and more Kentucky for my mental health?” Our mail order pharmacy is out of Mobile, Alabama and they’re the nicest. We’re friends and we just joke and have a good time… such good people. The United States just feels to me like a whole bunch of different countries. Especially now.
A lot of the claimants go political on me and I don’t want to go there. It has nothing to do with what we’re doing right now, I'm trying to find you a solution. But that’s what’s so hard for me, professionally and emotionally, because your hands are tied. There’s nothing I can do to help them. Thursday, I had to log off… I told my supervisor, “Nope, that’s enough. This is verbal abuse.” “Oh, you should escalate those calls.” You guys aren’t available because there’s all these new people that need help and you want to put an irate person that’s ready to come through the phone on hold for 20 minutes? Probably not. I try the best I can since I am one of the seasoned reps. They’re not going to tell them anything different than I am. And that’s probably going to tick them off even more.
I’m mentally wiped out. Thursday when it was so out of control, my blood pressure just shot through the roof… that was an acute anxiety attack, that’s what that was. There’s a lot of things that the corporation… they’ve taken away some of our benefits. We were due for a merit raise at the beginning of the year, and “Oh, the rest of the departments aren’t doing that.” We’re making a ton of money for them and being worked to death. And the new people that are getting hired are being hired without training at a higher rate than what I’m getting paid now. But I'm going to be 60 this year… what do you do? But to me, I see a light, it’s coming.
I’ve seen the way people act out there when I pick up my own medication. It’s like, “Oooh. I think I've talked to her on the phone.” I’ve even stepped in; we had a big old long line and she’s just going off and the pharmacist is just… Finally I go, “You know what, you’re not the only one here and I’m sorry you’re having an issue but you’re holding up everybody and apparently you don’t care and you’re treating him very disrespectfully.” When she left the pharmacist goes, “I would hug you if I could right now.” I do this over the phone every single day but the advantage of that is that I have a hold button.
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