You Are So Very Welcome

Ellen Berliner offered the caller a ready excuse that her system was incredibly slow that morning. What with the holiday coming up and Covid going around there were simply an awful lot of calls coming in. It rolled off her tongue like the lines from a well-rehearsed play. Ellen also rolled her bored eyes. “We’re experiencing unusually high call volume,” a quote taken directly from the Post-it permanently taped to her monitor. She apologized, per another Post-it, and moved to the topic at hand. “Now what date was the claim again?”

An aggravated gasp came through Ellen’s headset.

“I’ve been on hold for like 20 minutes!” said the caller.

Ellen’s systems were not slower than usual that morning or any other morning. None of the associates’ systems were slower. Ever. It was the standard excuse generated by representatives of the GoToHellth Insurance Company. The real name was United National Healthcare Corporation, a blandly sinister integration of United, National, Health, and, in last place, Care. The employees thought GoToHellth captured the culture better.

What had kept the claimant on hold was Ellen’s trip to the bathroom, a stop at the coffee room where she got herself two Keurig cups of hazelnut coffee, a brief exchange with a colleague about lunch plans, and a walk back to her cubicle.

“Is the policy in your name?” she asked.

“My God, I told you already. Yes, it’s my policy, for me and my family. I’m on Cobra. That’s $1836 per month, and you’d think I wouldn’t have to call three times to deal with this…”

“Just a moment,” said Ellen. She put the caller on hold to cacophonous sound of a saxophone interrupted every few seconds with a voice that repeated, “Your call is important to us.” Ellen did not need to search for the claim details; she had them on the screen all along. What she was struggling with was a three-letter word for meadow. After a minute she wrote LEA in the puzzle then reconnected.

Yes, the claim was denied,” said Ellen.

Ellen and her colleagues had been trained to use the passive voice when discussing the downside of policies.

“I know that already. My question is why?” fumed the caller.

Ellen explained with coached patience that United National required more documentation from the provider to determine the appropriate level of reimbursement. She shared sympathy that the claim was for a procedure that had been submitted multiple times before. “I don’t know how this one ended up in that department.” Still, she explained, that the cost of the procedure would be allowed; she’d see to that. Then, in a confidential aside, she cautioned the cost of the treatment, in this case physical therapy, would only apply to her out-of-network deductible, which hadn’t been reached for the current year. It was, Ellen reminded her, only April.

“There’s a list of in-network providers on our website. The deductible is lower if you stay in-network,” she added.

The claimant had choice words about deductibles, in-network providers, and co-insurance, fulminating on the BS cost of the plan, and how they denied more than they accepted. She slammed the phone down before Ellen had a chance to ask if she would like to participate in a survey. 

It was the third slammed phone that week and it was only Tuesday. She hit ‘completed’ on the customer’s file, putting a conclusion to this claim.

Her phone was ringing again.

“Hello, United National Healthcare where our clients are our most important asset. How can I help you today?”

Ellen didn’t need to reference the employee guidebook for that line; she knew it by heart and instinct. The line was part of the collection of studied responses designed by a well-paid neuro-linguistic programming firm to keep interactions unemotional yet empathetic in a noncommittal way. The intent was to avoid tears, screams, pathetic pleas and calls to the state’s insurance overseer. There was the unspoken goal of exhausting people into just giving up on a claim or stretch out the process where a successful outcome could be as simple as “Well, you’ve hit your deductible.” It was frankly amazing how often the caller at the other end would say, “Thanks for your help.” And Ellen would respond appropriately with a “You are so very welcome.”

She left out what was always on her mind at those moments: “what an idiot.”

Before failing her physical therapist licensing boards…the first time, not the second time…Ellen would never have said “idiot” out loud about her professors, fellow students, or patients. She did say it about herself when she saw her scores and said it about everyone else when her advisor, Helen Adler, advised a repeat of her senior year. Ellen had said, “What an idiot.” Adler returned a smile and with a former smoker’s smug rasp said, “You are so very welcome.”

Helen Adler’s cold response ended that conversation. Ellen made a note.

The recruiter for United National found Ellen’s resume on LinkedIn via an algorithm that cross-referenced PTs who had taken their licensing boards and were still looking for work 90 days after the test results were released. The recruiter’s database flagged those who'd taken the exam more than once; they’d prove ideal candidates.

“Are you looking for a career in your profession? One where you don’t need a license?” These were magical words to the depressed and disenfranchised fretting their limited options, wondering if they’d thrown away years of education.  

The recruiter explained the health-insurance industry needed professionals who might be more suited to an office than a clinic, who had the knowledge to understand medical evaluations, and could, “like a detective,” she’d said, help determine if a given treatment was genuinely warranted, or, and she left this part out, whether the patient could hobble along in agony for the rest of his or her life and save the insurance company some money.

Never, not once, had the recruiter been called out by someone saying, “So what you need is an unlicensed PT, OT, MSW, fill in the blank, to say “no” to paying for treatment.” 

Ellen’s colleagues accepted their fate or saw it as a temporary step as they studied for another shot at their license. In the meantime, they justified their work with excuses ranging from “well someone has to” to calling it “a crusade to stamp out corruption.” 

At least it was employment in the once-chosen field for which they failed to qualify and a chance to challenge the expertise of people who did. That made the bitter aftertaste a little sweeter. Ellen was particularly bitter making her particularly good at the job.

“Hello, United National Healthcare where our clients are our most important asset. How can I help you today?”

The caller didn’t respond immediately forcing Ellen to repeat the canned phrase. “Yes,” came back in a strained sotto voce. Ellen screwed up her eyes as the caller attempted to get to the point. Ellen insisted without initial success to get the caller’s ID and group number until, against protocol, she said, “Stop it. I’m about to hang up if I don’t get your ID and group number.” 

“All you had to do was ask,” huffed the caller. Or was it more a rasp than a huff? Ellen typed in the numbers. She had a grin like the Jack Nicholson character in The Shining when she saw the name that appeared on her monitor.

“Well now. How can I help you, Helen Adler?” Help was the last thing on Ellen’s mind.

Helen Adler’s long-winded explanation followed the trunk of a very large decision tree following up and down each branch as the tree grew in length. There was no need. In front of Ellen was the electronic paper trail of a claim filed, sent to the wrong department, refiled, sent back to Adler for more information stating some data couldn’t be read even though the scan on the screen was quite legible, and documentation of her multiple calls.

I do understand your frustration,” said Ellen. “You don’t want to…” Ellen was about to say “go back to school” but caught herself. “You don’t want to go through this again. Let me give you a case number if you have to reference this call.” The case number hadn’t changed in the three prior episodes when, according to the file, it had been provided to Adler.

“Please, I just gave it to that woman, Sheila something, before she transferred me. I was on hold for over 10 minutes.”

Ellen took note of that; the usual wait time was slated for at least 20 minutes.

“Give me a moment to review the file. I’m going to put you on hold for just a moment.” 

Ellen heard an aggravated “But wait” just as she muted Adler’s call.

It was clear what was going on. Adler had a simple case of tendinopathy after a week of skiing in Aspen. “She can afford that?” thought Ellen. She bit hard on her sucked-in cheeks at the image of her former advisor skiing in Aspen. And she had dared to see an out-of-network physical therapist, out of state, for an expensive series of treatments. The claims were initially denied due to improper paperwork - older employees of United National called that the ‘hanging chad’ excuse – but the intent was clear to anyone who knew all 26 letters in the alphabet; postpone. Any fault could be cited,: black ink instead of blue ink, printing a name instead of a signature. Or triple checking the license number for an out-of-network provider.

It was a philosophy United National embraced.

PT claims were habitually refiled, lost, refiled, sent to the wrong department, and finally landed on Ellen’s lap. As a trained if unlicensed PT, she was either the light at the end of the tunnel or barbed-wire topping the chain-linked fence at the end of a dark alley. 

Ellen was the eternal clerk behind the counter of the DMV; she could either point right, in which case the claim was approved, or left to the “get-back-on-that-line” heap.

The screen in front of Ellen showed that even by United National’s standards, Helen Adler’s case was a doozy. Several of the procedures had been signed off pending approval. Ellen was in the position to authorize, a.k.a. reimburse, them if she so chose, or send Helen Adler’s stone of Sisyphus rolling back down the mountain.

There was a sob followed by sniffles and then a rallying cough. “I’ve provided ‘further details’ so many times,” Adler said and listed each date, each action taken, and the identity of the United Health employee she’d spoken with. “And, for my records, what’s your name?”

“Um,” said Ellen.

Ellen looked at the surrounding cubicles. What she needed was a name other than her own. Page 21 of the manual started the ethics section and the ethics section made one thing abundantly clear: you could cajole a claimant to your heart’s desire, but you could not handle a claim of someone you knew. That was a conflict of interest that would bring the insurance regulators down on United National like a year’s worth of unreimbursed claims. The example cited was of a client who sued United National after his invasive procedure was denied by a still-angry former girlfriend. The state’s regulators did their own invasive procedure on United National. United National changed the manual.

“The individual’s role was terminated.”  

The passive voice was consistent with how the firm communicated uncomfortable information. The active tone came in the next sentence. “The former employee cannot legally work in a regulated industry again.” That was problematic for Ellen because said former employee had trained as a Physical Therapist. Ellen’s duo of inadequate board scores came back in a flash.

“Just a moment,” said Ellen.

Her colleagues looked busy. Janet, an obese PT, was talking into her headset. Janet had worked in a clinic, fully licensed, until the weight got in the way, got in everyone’s way. Bill – a former chiropractor who had to give up that job due to a bad back – had his eyes were closed. He was twirling a pen around his thumb in a distracted way. He must have had someone on hold. 

Up and down the cubicles Ellen looked for a name, someone who’d cover for her. Yeah, right. She considered making up a name, but Helen Adler had a case number and she’d entered it in her screen; her name was already registered. She considered hanging up, but Helen Adler would just call back with that damn case number. 

Ellen stared at the blinking red light on the phone console that had an angry Helen Adler at the other end. A queasy warmth expanded into her throat causing a slight gag as her whole body started a reflexive heave. Ellen grabbed for the trash bin under her desk, relieved to see the white plastic liner. The heave was about to manifest itself into the bucket when Ellen heard words of inspiration. 

“I do apologize. I’m not really sure how this happened, but it all looks good to me. You have more than met your deductible. I’ll see you get the allowed reimbursement for this.”

Ellen’s oozing warmth retreated.

“Please, there’s no need to thank me.”

It was Janet, now rewarding herself with the first of two Subway Chicken & Bacon Ranch Sandwiches that were her Wednesday’s meal-du-jour. She’d gotten thanks for, in essence, applying a claim to a deductible at a petite cost to United National. And when another claim followed? The rigmarole would start over.

Ellen took Helen Adler off hold.

“I’m so sorry for the delay. I had to pull some strings.”

Ellen cut to the chase after another ten minutes reviewing the long paper trail Helen Adler had been following. Being deliberate and detailed was also in the manual, though not specifically mentioned as a technique to numb the customer. Helen, too, had met her deductible and so further claims would be paid out at 80% for in-network providers, after co-pays, and 60% for out-of-network. Ellen gave her the website where she could find those coverage tidbits.

“And I’ve authorized the allowable, the maximum allowable, reimbursement for this claim. That’s fifty-six dollars and twenty-nine cents. You’ll get that within two weeks.”

Nothing came out of the  other end of the line. Ellen looked to make sure they were still connected. “Hello? Ms. Adler?”

“I’m here. I’m just, you know, exhausted from it all. But, anyway, thank you. You know, I don’t think I caught your…”

“Name? Let Sheila take the credit,” said Ellen. “Oh, and Ms. Adler? You are so very welcome.”