Date Published: January 31, 2023 - Last Updated 144 Days, 4 Hours, 8 Minutes ago
At the start of the new year, I was given an unwelcome surprise at the pharmacy. Instead of being given the usual medication at the counter, I was given a generic version of the drug. Without notice, my pharmacy benefit manager (PBM) booted the name brand medication off its formulary and replaced it with a generic.
This lack of communication when it comes to formulary change is fairly standard practice for PBMs, but it feels like an unforgivable sin to customer experience, especially when it comes to something as sensitive to the customer as medication.
Be that as it may, switching a name brand of a drug for a generic often isn’t an issue, as generics are designed to work almost exactly like the name brand. However, there are certain conditions in which, for whatever reason, the generic simply doesn’t cut it for some patients, and this was the case with this condition.
(I am being a bit vague here about the condition out of respect for the medical privacy of a family member.)
Thus began what has now been a two-week saga navigating the byzantine labyrinth that is the U.S. system of medical health insurance. There were rules and procedures for filing an appeal of this decision, and we immediately appealed, and are still appealing.
Throughout this process, I’ve spent a great deal of time talking with the frontline agents for the PBM. In the midst of my sometimes volcanic inner rage about the dead ends I’ve reached during this saga, I also have felt a great deal of sympathy for the agents on the other end of the phone. They were courteous and sympathetic, but they also were completely handcuffed in their ability to deliver good customer care. That’s because their system wouldn’t provide them the most up-to-date or full information about the status of the appeal process.
When I spoke with the agents, they were often at least a week behind in the process. For example, I had received a letter with a determination of the first level of appeal the day of one of my calls, and the agent on the other end said they wouldn’t have that information in their system for another month.
And not only would I have to explain to the agents what step in the process we were on, I even had to explain the basic process of how preauthorization for medicine worked. Most of the time, these agents would be discussing issues of payment and shipping, not how to navigate the shortcomings of the medical system.
To deal with the fact that they had little understanding of the process or up-to-date information, the agents would attempt to loop in their managers. I was placed on hold for minutes at a time, but never allowed to actually speak to the managers. Instead, the agents had to play a game of telephone and explain what their managers said. Invariably, information was left out, and the process would start over again.
From this exhausting and ongoing experience, there are a few basic suggestions for best practices for any contact center:
- It is always better to communicate fully and clearly about a policy change before it happens. Customers should never be surprised by a change, and frontline agents should never be put in the position to explain the change for the first time to a customer.
- Any information sent to the customer must also be immediately registered in the system, especially when it comes to complex cases like this one.
- Agents must be fully trained in every step of a procedure involving their products.
- If this isn’t possible, there must be a clear process to quickly transfer to uber-agents who can fully navigate complex situations and customer requests.
- If information is restricted from view for frontline agents due to privacy regulations, then it’s vital to make sure that customers have access to representatives who can discuss the issue fully.
- Preferably those uber-agents should be easily accessible via quick transfer or even a separate phone number.
This may require some investment in training and process up front, but it is better than facing the shortcomings in training and process in real time with an exasperated customer.