Pharmacy Benefits 101: Building an Award-Winning Call Center from Scratch

We’ve talked and written about different behind-the-scenes processes, like networks and prior authorizations, and how they are designed to aid plan sponsors and members. But if there’s one part of healthcare that needs no introduction, it’s customer care. Well over 50% of Americans are covered by employer-sponsored insurance, so it’s more likely than not that someone – whether it’s the plan member, a dependent, or their provider – has called the customer care line to get assistance or answers about a specific concern.

Here at Capital Rx, we are proud to have an award-winning, world-class customer care center that routinely achieves industry-leading Net Promoter Scores (NPS) and leverages Judi®, our proprietary enterprise health platform, to enhance service quality. How did we set it up? How do you maintain a Customer Satisfaction Score of 96% or better for four years running? Will Tafoya’s (SVP, Customer Care) leadership has been critical since day one. Having worked in call centers since the ‘70s, he understands what works, what doesn’t, and what’s missing from modern call centers.

We chatted with Will about the pieces that go into making an award-winning customer care center and how modern technology, like Judi, creates a better experience both for call center operators and for members & plan sponsors.

Expertise Matters in Customer Care, Especially for Pharmacy Benefit Managers

Hiring Pharmacy Technician Certification Board (PTCB) certified pharmacy technicians and other healthcare professionals for customer care roles was one of Will’s first initiatives after joining Capital Rx. The reason for doing so was relatively simple: these individuals come with a healthcare background and pharmacy and/or payer experience. That is key to being able to care for plan members in a pharmacy benefit management (PBM) or pharmacy benefit administration (PBA) environment.  

Additionally, thanks to the culture our customer care team has fostered – one that’s supportive, grounded, and rewarding – there is word of mouth in the labor pool, a lot of pharmacy technicians are as interested in joining our team as we are in bringing them onboard.

“One of the things I’ve learned over the years is that customer care has to be knowledgeable about everything that occurs within the organization to be able to effectively serve the plan sponsor or member that’s calling,” Will explained.

This expertise goes beyond simply being able to pronounce drug names effectively, or being able to facilitate calls with both providers and pharmacies as needed. Yes, those things are important, but it’s also about being able to understand what disease state a medication is being prescribed for or more nuanced issues.

While customer care team members are not clinicians, having relevant experience enables our team to speak more intelligently and diligently to the therapies these medications are being used for. These factors help lead to a better experience, meaning members and plan sponsors get their questions answered or their problems resolved in an efficient and satisfactory manner.

Collaboration is Critical in a Virtual Call Center Environment

Capital Rx’s call center is entirely virtual, which removes geographical and other limitations on the talent our leadership team can source. On top of that, while brick-and-mortar call centers can be impacted by natural disasters, a virtual call center is somewhat insulated from that risk, as team members in other parts of the country can provide support when others are impacted by a natural disaster, for example.  

However, as Will explained, meeting the challenges that exist in a virtual environment requires a rigorous approach to internal processes.

“One of the things I’ve learned, since we are a 100% virtual contact center environment, is as long as your processes and your expectations are clear and concise, then we are good to go in a virtual environment. Of course, things are going to happen. We understand that, and we help people worth through those situations.”

Capital Rx’s customer care team is very detailed when it comes to internal processes, especially with respect to how it works with other teams within the organization. For example, customer care has ongoing partnering meetings with the Clinical and Finance teams to align expectations and needs.

This collaboration also helps prevent information silos, which are often prevalent in call centers, especially as organizations grow.

Additionally, given the nature of the call center, it’s typically the primary touchpoint for a lot of different cross-collaborative efforts.  

“From that perspective, our team is able to detect that there’s an issue – let's say with claims adjudication. And we’re getting calls from pharmacies having trouble processing claims. We’re able to quickly escalate that internally to the appropriate work group so they can start looking into and solving the issue,” said Will.

Understanding the implementation process is also key for the customer care team. Every team comes in with different expectations and needs (not to mention the cultural differences within those respective workplaces) and understanding the nuance between each client is critical.

That’s why customer care team leadership at Capital Rx sits down with clients, from employer plan sponsors to health plans, during the implementation process for open, thoughtful discussions. They cover questions like:

• How do you expect us to engage with you?
• How do you expect us to engage with combined membership?
• What is it you want us to focus on when we’re providing the agreed upon level of service?

This dialogue helps provide a clear understanding of the client’s service expectations, and how to provide input and feedback. At the end of the day, client support and member care must be collaborative to provide the level of client support and member care that everyone needs.

Related Content‍

• Capital Rx’s Customer Care Team Wins 5 Stevie® Awards for Customer Service
• How Our Favorite New Judi® Features Aid Pharmacy Benefit Administration
• Capital Rx’s Judi® - The Beauty of an Open Platform

Leveraging Modern Enterprise Health Technology for a Better Benefit Experience

We talk often about the ways plan sponsors can leverage our proprietary enterprise health platform, Judi, but it’s also a single source of truth that teams across our organization use every day – including the customer care team!  

Since Judi is a central “hub,” our customer care team can easily and securely access data as needed to address a member’s question or concern. That is not commonplace in the industry; in fact, it’s more likely that someone within a call center at a traditional pharmacy benefit manager or other health plan must access multiple systems just to answer a simple question.

As Will recalled, “In my job prior to this, we had to look at four different systems to answer one simple question and make sure the answer we were providing was accurate. If you think about the member's experience and efficiency, Judi gives us the ability to provide an outstanding level of service, greater efficiency, and better accuracy. Plus, if I can use Judi with little to no training, anybody can do it.”

So how does our customer care team leverage Judi in their day-to-day role? Judi provides representatives with patient and family structure information, medication information, and information about claims and prior authorizations that may be processing, among many other things.

This enables our representatives to have, in effect, a one-stop shop to do anything and everything necessary to support the caller. This is part of the reason Capital Rx’s call center consistently achieves a First Call Resolution (FCR) rate in excess of 95% and has a 99% Customer Satisfaction Rate (CSAT).  

Another reason Capital Rx’s customer care team can solve questions on that first call is there’s no target average handle time here. The goal is for issues to be resolved, no matter how long it takes, so that members do not have to call back repeatedly to get their questions answered or their concerns remedied.

The Future of Customer Care in Healthcare and Role of Artificial Intelligence

So, what does the future hold for customer care? And what innovations can be leveraged to make the experience more seamless and efficient for callers?

One of the things the Capital Rx customer care team is currently doing is going through an exhaustive vetting process to evaluate providers to help us build and leverage AI. But it’s important to our team that we’re not just engaging in call deflection – where you look at service through the lens of which types of calls can be automated.

While there are calls we could automate with relative ease, given the technology that’s out there today, we want to be mindful of the caller’s experience. So, there will be types of contact our system will offer to the caller, like self-service options, or enabling a pharmacy to submit a clarification code to see why a claim is rejecting. This would free up our agents to focus on more complex issues and concerns.

“Our objective is not to have a negative impact on our customer satisfaction. That’s why we’re setting up a number of checkpoints as we continue to evaluate these technological options and their capabilities, making sure we’re doing the right thing and creating efficiencies while still providing the level of service our clients and our members expect.”

Learn More About Our Approach to Customer Care

At Capital Rx, our customer care team works on the front lines, fielding calls from clients and members, answering questions, and finding solutions. That’s why it’s so important and exciting that, year after year, they exceed expectations.

Click here to listen to episode of the Astonishing Healthcare podcast featuring Will Tafoya, AH034 - Customer Care in Healthcare: Setting a Higher Bar, where we discuss Will’s path to Capital Rx and our approach to customer care, how the team leverages Judi, and much more!

If you would like to learn more about Capital Rx’s full-service PBM or PBA solutions, including our clinical programs, CLICK HERE to get in touch with our team.

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