AH086 - Balancing Technology and a Human Touch in Member Service, with Lisa Ellerhorst and Sonia Pettis

Transcript

Lightly edited for clarity.‍

[00:22] Justin Venneri: Hello, and thank you for listening to another episode of Astonishing Healthcare. I'm Justin Venneri, your host, and we've got a great discussion lined up for you today on member care or how our team on the front lines helps ensure that health plan members are taken care of when they need help and they call in or reach out to us. Time and time again, we hear that cost and member care are the most important factors for plan sponsors when considering their health benefits partners.  

And we had a great conversation on how we set up our contact center and some of the KPIs we track when Will Tafoya joined us last year for episode 34 - and I’m kind of in disbelief that we're in the 80s now, episodes-wise - but here we are. So I've got Lisa Ellerhorst, Senior Director, Customer Care Operations, and Sonia Pettis, Manager, Customer Care Operations, in the studio with me today, and I'm super grateful that you both could take the time out of your busy schedules to join us for this and to share some of your vast knowledge and experience. Lisa and Sonia, thanks for being here today.

[01:17] Lisa Ellerhorst: Well, Justin, I am thrilled to be here today.  

[01:17] Sonia Pettis: Thanks for inviting me as well, Justin.

[01:24] Justin Venneri: Okay, onto the questions. Lisa, start us off with your background and your role here, please.

[01:29] Lisa Ellerhorst: Yes, Justin, I joined Capital Rx in October of 2020, and I'm now celebrating my five-year anniversary this month.  

[01:37] Justin Venneri: This month? That's awesome. Congrats.

[01:38] Lisa Ellerhorst: You know, it's hard to believe five years have passed. My current role is Senior Director of Customer Care Operations. But before joining Capital Rx, I spent nearly 20 years in the PBM industry with National RX Services Medical Health. I have over 30 years of experience in customer care.

[01:56] Justin Venneri: And Sonia, I'm excited to have you on, too. Tell us a bit about your past and your path to Capital Rx, please.

[02:01] Sonia Pettis: Of course, Justin. In my current role as Manager of Customer Care operations, Lisa and I joined the company together in October 2020. So, I'm very happy to say that I'm celebrating my five-year anniversary as well. I have 25 years of experience in the pharmacy and PBM industry, including 17 years with a previous PBM and nearly five years at Capital Rx.  

I'm also very happy to say that my career began as a pharmacy technician in a retail pharmacy for eight and a half years, which helped to provide me with a solid foundation for my work in customer care and PBM operations.

[02:35] Justin Venneri: That makes a ton of sense. Okay, so a lot has happened in the last year. Lisa, back to you. Can you share some high-level information to just frame things up for the discussion of how things are going?

[02:46] Lisa Ellerhorst: This year has been eventful, just like the many years I've been with Capital Rx, and we continue to evolve. During the second quarter, we initiated our transition to a mail service pharmacy partnership. I think Sonia is going to share some additional information later, but I want to emphasize that our main goal during this transition was to educate our members thoroughly so we help our patients navigate our offerings effectively, thereby ensuring that they have a positive and enriching experience throughout their engagement with us.

And you know, it takes constant effort, and we're always looking to refine our processes. But we take pride in our member satisfaction score. I think the year-to-date increase in call volume compared to last year is around 50%. So, to maintain a 99% satisfaction score with that type of growth is incredible. Plus, we've seen a significant evolution with a shift to helping service medical calls for our own population. So things are going well overall.

[03:43] Justin Venneri: Yeah, I think that's one of the most astonishing things to me is that we've seen this growth year over year, member growth and then call growth like you said, as you'd expect. And you and your teams have been able to, you know, stick that member satisfaction score in that 99% range since I've been here over three years. So, that's awesome.  

Last year during the recruitment season, Will and I talked a little bit about this, there was quite a bit of optimism about the hiring environment and our ability to attract and retain talent. Will talked about how things were looking. The rationale for finding great PTCB-certified representatives. Lisa, can you please remind us why that's important beyond just the need for increased capacity and scaling as our covered lives and call volume grow?

[04:24] Lisa Ellerhorst: Absolutely, Justin. You know, we take great pride in our ability to track exceptional talent, and we are currently deep into our recruitment efforts for the 2026 welcome season. Our hiring strategies are meticulously designed to align with our organizational goals and we emphasize on recruiting highly skilled pharmacy technicians to strengthen our team's expertise.  

Once these talented individuals join us, we prioritize their long term success and satisfaction through a nurturing approach. We prioritize by the unwavering support and guidance our leaders provide them. This holistic approach ensures that our team thrives together, fostering growth and of course innovation. We all know a well scaled operation reduces burnout, improves our training outcomes and creates a more supportive environment for our frontline teams. This of course leads to better performance and lower attrition.

[05:20] Justin Venneri: Okay, and Sonia, so maintaining performance with a highly skilled team and in a rising call volume environment. How about we just dive right into what those calls are about? Could you share some of the top call drivers that we've seen over the last year and change? Do those change much over time?

[05:35] Sonia Pettis: Some of our top call drivers include claim status, mail order, drug coverage, and eligibility. We encounter members that call to ask about GLP-1 medication coverage such as Mounjaro®. Our members want to know why the claim was rejected and what steps can be taken to resolve the issue. We always first listen to the members concerns and then of course we verify their eligibility.

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[05:59] Justin Venneri: You just jumped right into to like one of the hot button topics. I appreciate that. I wasn't expecting that. So what happens next?

[06:08] Sonia Pettis: So the next thing that our team does is we make sure to review the claim details in duty to identify the reason for any rejection, which in most situations is due to the drug requiring a prior authorization. Once our team identifies the issue, we always make sure to clearly explain the reason for the rejection to our member. If a prior authorization is necessary, we've offered to reach out to their prescribing physician to start the process, ensuring that our members have a smooth and supportive experience.

[06:37] Justin Venneri: With regard to some of the other issues, like drug coverage. Could you guide me through how our team handles a member who calls in, maybe to inquire - you mentioned mail order, so to inquire about transitioning their mail order service or to mail order service from retail?

[06:52] Sonia Pettis: Certainly. Again, we always make sure that we fully listen to our members’ concerns to understand the reason for their call and what prescription they're referring to. We then confirm their eligibility for mail order services based on the member’s plan design. We follow up by assisting our members in navigating the mail order enrollment process first, beginning with helping them to set up their online profile. If necessary, we coordinate directly with our mail order pharmacy partner to ensure everything is set up smoothly.  

This can include a series of questions as well that's used to help to set up the profile on their end. And lastly, to help our members fully benefit from mail order services, we always offer to contact the prescribing physician to request new 90 day prescriptions because we always want to make sure that Anything that we help our members transition through is smooth and we like to maximize on convenience.

[07:45] Justin Venneri: Okay, Another scenario that I think comes up pretty regularly. What if they have mail order and want to switch to retail? So the opposite maybe they encounter an issue canceling the mail order or faced a cost problem at the counter. How do you handle that?

[07:59] Sonia Pettis: Of course. So we understand that transitioning from mail order to a retail pharmacy can be challenging and if our member has trouble canceling their mail order prescription, we first verify has their order been processed and shipped, and our team can do all of this in real time. If it hasn't been shipped or processed, we work with our mail order partner to make sure that we cancel the order to avoid any unnecessary charges. We then continue by addressing the cost concerns at the retail pharmacy. We review the member's plan design to confirm copay amount and help them to understand the differences in coverage between mail order and retail options.  

Our team captures claims in real time, allowing us to identify the benefit stage that our member is currently in. This also enables us to be able to answer any questions regarding copays or coinsurances, all while on the call. Lastly, we always make sure that our members are informed throughout the entire process. We always offer to reach out to their provider if a new prescription is needed, and we always make sure that they understand their available options. We do this to ensure that our members feel empowered to make the best decisions for their care and budget.

[09:08] Justin Venneri: And how about if a member calls with like as comes up a lot these days formulary questions. Are these covered medications? I was just written this prescription. I want to understand if I'm going to have to do something special or if it's covered by my plan. What if the situation is more complicated and requires a follow up? Will said last year like we don't have an average handle time target. Really it's like make sure that the members questions are answered so they don't have to call back. I'm paraphrasing but I think pretty much what he said. So how much time do you spend explaining things to them and helping them find a medication that maybe they got a prescription for if they're maybe if it's not on the formulary.

[09:41] Sonia Pettis: Our top priority is to always ensure that our members have the clarity and support that they need to make informed decisions about their care. So to answer your question on how much time do we spend with our members, we do not measure success by speed. We rather focus on thoroughness, taking the time to explore all available options, carefully reviewing benefit details and Engaging our clinical team when appropriate. This approach allows us to deliver meaningful, personalized support that truly puts the member first as well as ensures access to care.

[10:14] Justin Venneri: Okay, got it. So leveraging Judy and our clinical team, you guys are able to pretty quickly see and explain formulary related questions to members that call in. Is that fair?

[10:23] Sonia Pettis: Absolutely.

[10:24] Justin Venneri: Okay. One thing that comes up. You mentioned prior authorizations. What if a parent needs prior authorization for their child's medication, like a Dupixent® or something like that, and they're confused about the process? How do you help in those scenarios?

[10:36] Sonia Pettis: Well, we always recognize how crucial it is for a parent to get assistance with their child's prescription, and we always make sure that the process is quick and without complications. When a prior authorization is needed, we always take the time to clearly explain the process and offer to contact the prescribing physician directly to help initiate the request on behalf of our member. Throughout the entire process, we also make sure that our member is informed at every step, ensuring that they feel supported and confident in their care journey. We also assist our members in having their prescription sent to our specialty pharmacy partner, ensuring that they experience a smooth and timely transition for easy access to care.

[11:19] Justin Venneri: And I would assume, sorry if this is a silly question or “Captain Obvious,” but, you know, Dupixent is for inflammatory diseases, right? Like, but if it's an inhaler or something like that, are there other common conditions where you encounter this sort of thing, where you have to help a parent out for their child?

[11:32] Sonia Pettis: Well, we definitely encounter this situation for all classes of medications. So, we strive to not make one drug appear more important than the other. Rather, we just want to always make sure that our members have access to care that they need for themselves or anyone in their family.

[11:49] Justin Venneri: Got it. And Lisa, back to you. Thanks for hanging on there through the scenarios. We briefly discussed the use of AI in the contact center last year. And I know this is one area where there's a lot of debate about the use of chatbots. Do you have any updates on internal usage or what are your thoughts on the use of AI in customer care? How's that evolving?

[12:06] Lisa Ellerhorst: Yeah, absolutely. There's been meaningful progress since we last spoke about AI in the contact center. Our AI team has developed a prototype agentic AI bot designed to engage directly with our callers. Its initial capabilities include identifying the reason for the call, and then validating HIPAA authentication and responding to specific inquiries. Let's say prior authorization.  

Over time, we will build out more capabilities, but one of the key objectives has been to pinpoint Repetitive, relatively simple tasks that can be automated. By doing the automation, we're freeing up our live agents to focus on more complex, nuanced issues that require human judgment and empathy. It's a thoughtful balance between efficiency and experience. And we're excited about the potential this technology has to elevate both of those.

[12:59] Justin Venneri: One thing, I'm just curious for your thoughts on the one thing I've always liked and asked. Now I'm going to get a little bit salesy. I always promise not to get too salesy on these holes, but in marketing we're telling a story about our service and I, I try to validate those things. So I would like secret shop and just call and it was the nicest thing was not having to yell at an automated system about a prescription or a benefits question.  

And so I could get someone online pretty quickly. I think the investment in AI in the contact center is amazing and has a ton of potential, like you explained, to improve the experience. How do you think about balancing that role of technology and making sure that we can get a person on the phone pretty quickly if the AI can't figure it out? Is that a big, big part of the evaluation of these tools?

[13:39] Lisa Ellerhorst: Oh, absolutely. It's always something that we look at. Again, we've talked a lot about access to care. We're educators, so we want to make sure that we're taking care of our patients. So if we find that the agency agent there needs to be additional follow-through, we will immediately get that call to the right hands. And that means one of our live agents that can review the information and provide the necessary care needed.

[14:03] Justin Venneri: Okay. And sticking with you, Lisa, I have a question on unified claims and Judi Health™, how are you approaching expanding our team and our capabilities to handle medical and pharmacy and vision and dental when they come on, it seems like we'd need some quote unquote jack of all trades or more generalists. Or does technology like our enterprise health platform, Judi®, does that help?

[14:23] Lisa Ellerhorst: It absolutely does. As we grow beyond pharmacy into medical, dental and even vision plan administration. Above all, our goal is to provide a seamless member experience. That means building a universal agent model so when members call, they don't have to navigate silos and get “bounced around” the organization to get help that they need.

[14:45] Justin Venneri: Yeah, I saw the air quotes there [laughter].

[14:46] Lisa Ellerhorst: Yeah, we've all been there. So, we'll continue hiring people with strong empathy and problem-solving skills while also looking for candidates that have a deeper background in the medical plan administration and of course, customer care. We will also be training some of our existing customer care agents beyond pharmacy, thereby building a strong bench of agents that can resolve issues across all benefits in one conversation and deliver a consistent, compassionate experience every time.  

All of this is of course made easier with Judi. As our product suite expands, we will see technology grow and evolve, enhancing our customer care approach. Our focus will always be delivering high touch, human centered service while leveraging the amazing technology that Judy offers which will enable an even better experience for our members.

[15:36] Justin Venneri: And here we are. The last question, thank you both for taking the time today to share your thoughts and experience on how things are evolving. The most astonishing thing you've seen or heard relating to this discussion - I'll start with you, Sonia, and we always have to have our compliance hats on. No HIPAA or PHI violations. Just tell us a good story to close out. Could be something good, wild, whatever. We'd love to hear the most astonishing thing you've seen that relates to customer care in the PBM or now medical benefits world.

[16:02] Sonia Pettis: Well, the most astonishing thing that I have seen is how seamless the customer care team handled the expansion of our transition to mail order, specialty, and LDD services. In 2025, our team took a very proactive approach to provide clear guidance on the new process. During this time, the team demonstrated unwavering commitment and resilience as they worked diligently to ensure a smooth and successful transition.  

This also included members in setting up their online mail order accounts, coordinating directly with our mail order pharmacy partner, and even contacting the prescribing physicians when necessary to ensure uninterrupted access to critical medication. Our goal was and always is to make sure any transition that our members are part of to be as seamless as possible while maintaining the highest standard of care and support throughout the process.

[16:56] Justin Venneri: And Lisa, how about you?

[16:57] Lisa Ellerhorst: Well, Justin, it's no secret I take great pride in the exceptional customer care team, and it's a true privilege to collaborate with such dedicated individuals each and every day. As I mentioned earlier, our team has achieved an impressive 99% customer satisfaction score. It's a testament to the team's commitment to excellence. In addition to this, we receive heartfelt recognition through what we refer to as a kudos. A kudos is awarded when a caller specifically requests to speak with a customer care leader to express their sincere gratitude for the outstanding service that one of our agents provided.  

These moments of appreciation are especially meaningful because they are unsolicited. The customer reaches out purely to commend the exceptional support they received separate from our structured survey process. This kind of authentic Feedback not only highlights the dedication and professionalism of our specialists, but it also reinforces the importance of the relationships that we build with each of our members. Each Kudo serves as a powerful reminder of the positive impact we have on people's experiences, motivating us to continue striving for excellence and to deliver service that leaves a lasting impression on each and every one of our callers.

[18:11] Justin Venneri: Yeah, that kudos channel and that flow… I think it's really rewarding for everyone to see, and especially like over the holidays and times when everyone's online, you know, 24/7, 365, of course. And you know, that recognition comes in, it's unprompted. That's pretty awesome to see.

So, I love that one. Well, thank you both for joining me today in the studio. It was great to get an update and hear some of those scenarios and how we handle them. Sonia and Lisa, thank you for stepping in for Will. It was excellent to have you on, and I look forward to having you both back hopefully next year to talk about how things are going.

[18:39] Lisa Ellerhorst: Thank you, Justin. We appreciate it as well.

[18:41] Sonia Pettis: Thank you, Justin.

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