Wrestling With the Unmanageable Side of Health Care
More than 220 readers responded to two columns I wrote criticizing telephone service. But not one employee of the phone companies mentioned contacted me to complain about his or her employer.
That hasn’t been the case with two recent columns on Prudential HealthCare. Eleven of the company’s employees wrote or phoned me, all saying they are troubled about the way PruCare, as many call it, serves its customers.
In its official responses, Prudential, too, has indicated it isn’t satisfied with the way it’s serving its customers. The chief corporate spokesman, Kevin Heine, has consistently told me the company is trying to improve.
Because Prudential HealthCare is one of the biggest managed care insurers, this may be a thin ray of hopeful light in a troubled industry.
These days, it’s easy to slip into cynicism about everything. It’s harder to listen to explanations and to try to be understanding.
The critical employees, who all requested anonymity, do not seem to share the view, given me by numerous Prudential customers, that the company is willy-nilly turning down proper claims.
Rather, the employees often contend that Prudential’s customer service is badly organized, staffed by many new people under great pressure to make too many decisions on claims in too little time.
Sometimes, they say, the system makes it easier to deny a claim than to approve one.
A detailed e-mail came from a Prudential employee describing conditions at the company’s new Los Angeles National Service Center, one of four such centers countrywide.
“Emphasis [at the L.A. center] is on individual production rather than quality,” he wrote. “Currently, an examiner is expected to ‘finalize’--that is, pay or deny--82 claims per day.
“This is roughly one claim every five to six minutes, which leaves little time for careful consideration of difficult issues. . . . Productivity is reported on weekly scorecards, and the cumulative scores are posted, by name, for all examiners to see. Few want to be in last place.
“Credit is given only for either successfully paying . . . or denying a claim. [Leaving it] pending for more information or referring it to someone with more experience . . . results in zero credit to the examiner for the time spent.
“Some of these examiners intentionally deny claims that could be processed correctly so they may meet the standard for production. They . . . rationalize that the provider or member will appeal the denial and eventually get paid correctly.
“This ultimately results in additional delays and an unnecessarily increased workload.”
I sent this and other messages to Prudential’s Heine with the senders’ names omitted.
In a written response, he began:
“We have experienced some problems in transitioning our claims and service functions . . . to the facility in Los Angeles. In too many instances, we have not met our own internal standards or those of our customers.”
But Heine called the employee inaccurate in some of the numbers given for performance quotas.
“The current average target for finalized claims in the L.A. facility is 43 per person, per day,” he said. “Experienced claims examiners are asked to meet higher targets. For example, those with 29 or more weeks of experience have a target of 82 claims per day, but those people right out of training are expected to process 14 per day.
“The average target will gradually increase from 43 to 77 by June of 1999 . . . reflecting the fact that we will have a much more experienced staff working in Los Angeles.”
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So, for the standard eight-hour day, minus 40 minutes for lunch, the average service rep is now expected to handle one claim every 10 minutes, and for those with 29 weeks of experience, the standard is one every 5 1/2 minutes.
Studying these figures, it is evident that most service representatives in the center are relative newcomers.
Of Prudential’s current service reps in L.A., Heine said 26% are college graduates and 41% more have done some college work.
Heine mentioned that 45% of all claims are processed automatically by the company’s computer system, so those handled by service representatives involve the more difficult cases.
He added, “It is true that an individual’s performance is posted. This is a . . . common and very important quality control and performance feedback mechanism in claims and call centers like ours.”
But this may breed tensions among employees. Some of them say the L.A. center is not a pleasant place to work.
“I am at this time looking for other work, and when I leave Pru I will entertain you with tales of racial discrimination, bad faith, overflowing toilets and managerial ineptitude,” one wrote me.
Heine called such assertions mostly untrue. “We have many mechanisms and people to try and deal with those kinds of complaints,” he said. “We’re not hearing those at all often.”
Heine also forwarded a message to him from an L.A. employee who said Prudential had gotten a bad rap in my two earlier columns.
“Most of the reasons the claims are not paid are because of improper billing [by] the provider [the doctor], improper codes, improper diagnosis, preexisting problems, a referral or authorization that was not sent in by the provider, and benefits that are not covered,” this employee said.
“Instead of the provider calling Prudential to correct their problem, in most cases they send the patient a bill and say that Prudential denied the claim and give the member 30 days before the claim goes into collection.”
This is indeed another view, contradicting most folks I’ve heard from directly about PruCare.
It might be a good thing for this company and others to organize their own dialogues with both their customers and employees, a first step at easing festering managed care problems.
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Ken Reich can be contacted with your accounts of true consumer adventure at (213) 237-7060, or by e-mail at ken.reich@latimes.com
