I’ll go first. I did lots of policy writing, and SOP writing with a medical insurance company. I was often forced to do phone customer service as an “additional duties as needed” work task.
On this particular day, I was doing phone support for medicaid customers, during the covid pandemic. I talked to one gentleman that had an approval to get injections in his joints for pain. (Anti-inflamatory, steroid type injections.) His authorization was approved right when covid started, and all doctor’s offices shut the fuck down for non emergent care. When he was able to reschedule his injections, the authorization had expired. His doctor sent in a new authorization request.
This should have been a cut and dry approval. During the pandemic 50% of the staff was laid off because we were acquired by a larger health insurance conglomerate, and the number of authorization and claim denials soared. I’m 100% convinced that most of those denials were being made because the staff that was there were overburdened to the point of just blanket denying shit to make their KPIs. The denial reason was, “Not medically necessary,” which means, not enough clinical information was provided to prove it was necessary. I saw the original authorization, and the clinical information that went with it, and I saw the new authorization, which had the same charts and history attached.
I spent 4 hours on the phone with this man putting an appeal together. I put together EVERY piece of clinical information from both authorizations, along with EVERY claim we paid related to this particular condition, along with every pharmacy claim we approved for pain medication related to this man’s condition, to demonstrate that there was enough evidence to prove medical necessity.
I gift wrapped this shit for the appeals team to make the review process as easy as possible. They kicked the appeal back to me, denying it after 15 minutes. There is no way it was reviewed in 15 minutes. I printed out the appeal + all the clinical information and mailed it to that customer with my personal contact information. Then I typed up my resignation letter, left my ID badge, and bounced.
24 hours later, I helped that customer submit an appeal to our state agency that does external appeals, along with a complaint to the attorney general. The state ended up overturning the denial, and the insurance company was forced to pay for his pain treatments.
It took me 9 months to find another 9-5 job, but it was worth it.
I worked for a company who always positioned themselves as way more important than they were and were hellbent on micromanaging everyone. It was all about image and corporate culture. I can play that game fairly well, but I wanted to minimize my time dealing with it. I was part of a small group of 3-5 subject matter experts who rank similarly to management, but didn’t have to manage anyone. This tended to isolate us from the McJob environment as we worked things out between ourselves and all the bottom tier managers were nice to us because they wanted us to help their employees. We were salaried and unlike most jobs which use salary to make you work more hours, here salary meant I could bend my hours more than most employees and do 4x10hrs or 4x9+4hrs and leave early every Friday. Sometimes my boss would tell us to leave early for the day or take us to lunch. Sometimes we’d go out to lunch when our counterparts from a client company were around. It was an okay gig and my direct managers were okay. Covid happened and upper management could barely stand the idea of anyone working somewhere other than their watchful eye so they try to drag us SMEs back into an mostly empty office calling us “essential workers” despite us being 100% able to do our jobs from home and fully nonessential in every meaningful way. I needed the job, so I went. Around that time we got a new manager who was supposed to straighten the place out (instead doubling down on every reason the place was shit). When I arrived at our mostly empty office I let myself into the IT closet and grabbed 4-5 monitors to build myself a monitor wall. I showed up in sweatpants. I took frequent breaks. I played Tux Kart on my phone. I played songs like “take this job and shove it” over my PC speakers while I was working. We put on techno music and remixed snippets of angry customer calls to it. (QA was vibing to the tune of our rebellion!) I raced my rolling chair up and down the isles and generally acted a fool, but not enough to get fired. Our small group of SMEs was tight knit and after a few days of acting our wage, one lady quit because she had kids and there wasn’t any childcare available yet because of Covid. Our manager basically forced her into it because he would not compromise. The governor was still telling everyone to stay home. This woman straight up rage quit telling our boss exactly where he could shove it and all of us were VERY clear with our boss that he would lose the rest of us if he didn’t shape up. Of course he knew best. The bossman was a fucking self-important narcissist and tried to call our bluff only to find himself with 0 SMEs a week or two later. I went home that night and found a new job with a friend. To top it off, I was in the process of switching roles at the first company, so when I left, I imagine they felt an extra sting of having to restart that search. Their mission was “asses in seats” and they would hire anyone to meet headcount on their contracts, so whoever replaced us may not even have known how to properly turn on a computer much less fix one. One fellow SME followed a former colleague of ours who got him plugged in elsewhere. All of us found new jobs in record time. They had been driving us too hard to really document much, so when we left I assume everything collapsed back to the level of 0-experience newbies with no guidance or product knowledge at all. The company must have burned enough people because they moved most of their activity to a new city and some of it offshore where they continue their bullshit to this day. That’s what you get when you piss off nearly every qualified individual in a market! My small team of SMEs was awesome and I would absolutely work with any of them again. The comradery was top notch.
I web searched our former boss and found him on a few job sites for “high earning professionals”. He got fired a bit after we all left and I’d like to think he’s working as a grease trap cleaner now. Then again, in America we fail up.