Excerpted from Wenger, Etienne. 1998. Communities of Practice. Cambridge University Press.
Ariel runs down the stairs. She has to be at work at 8:00, and with the traffic, she will need a lot of luck to make it. She should really stop using the snooze button. The fact is, she would rather go to work earlier and come home earlier. But it's people with more seniority who get to choose their hours first: they can take the 7:00 to 3:00 schedule. She had it for a while. It's a bit hard in the morning, but when you get off at 3:00, it's like you still have the day in front of you. Staying there until 4:00 makes a big difference. But now the office needed some people to answer the phones between 3:00 and 4:00, 50 junior processors have to stay later. Although she has been working in the claims office for well over a year, Ariel is still considered a junior processor. She has recently been promoted to a level 6.
Predictably, it's congested between Ridgewell and Lincoln. As her car comes to a halt, Ariel grabs the rearview mirror to check her makeup. Overall, she takes good care of herself She makes up, but discreetly, and dresses cleanly but not aggressively. Fortunately, the office is rather informal about appearance. You could spend a fortune otherwise. Of course, she could not go to work in shorts, but even jeans are OK as long as they are not torn. Altogether, there are not too many rules about dress, but it has been intimated on a few occasions that it is better to look somewhat professional and that appearance as well as behavior will influence promotional reviews. Besides, proper clothes make her feel better about her work. Today she made a special effort because some visitors are expected in the office: she is wearing her new woolen skirt and matching high heels.
Judith and Eleanor are already waiting for the elevator. "Hi, how are you?" She glances at the indicator: "L" for lobby and the steel doors slide open. The three co-workers step in hastily. The elevator has the soft, rose carpeting that covers the floors inside the building, and its walls are made of smoked mirrors so you don't feel encased in a small box. The inside is at once dark and well-lit: two rows of indirect spotlights, built deep into the ceiling, shine softly onto people's heads. Like the lobby, with its large glass entrance, its peach walls, and its marble floor, the elevator seems made for business suits and attache' cases, rather than for Eleanor's jeans jacket, lunch bag and thermos, or for Judith's bright sneakers. She still looks like a high-school girl. The numbers flip above the door. "Second floor," says the synthesized voice of the friendly elevator in the same old tone. Ariel can hear that voice in her head whenever she closes her eyes: "second floor."
The office occupies the entire second floor of the building - plus a large part of the third floor, where the clerical unit, the training class, and the employees' lounge are located. The second floor consists of one large room. Only the two management offices in the corners have walls.
But even these have large windows so that visually they are almost part of the main room. All that obstructs the view are the two square structures in the middle of the area: the elevator shaft with the entry hall, and the bathrooms. The two bathrooms on this floor are women's. There was no need to reserve a whole bathroom for the few guys who work here; they can just go upstairs.
The first thing Ariel does is walk toward her supervisor's desk to sign in. Since she is ten minutes late, she promises to make up for the time this very day. She will stay until ten past four. Before going to her desk, Ariel checks her bin: only one referral and nine pieces of mail. She usually receives a lot of mail addressed specifically to her. Ruth told her this happens because she always gives her name on the phone. It seems like the right thing to do, but she came to realize that many processors try to avoid doing so.
Ariel's desk is close to the supervisor's desk. Of course, she has to make sure that she does not chat too much. In fact, she suspects that it's the reason she was told to sit there. Before, she was sitting beside Eric, and he kept talking to her. Now she does not have much pnvacy, but that's good too. It helps her concentrate. She knows herself, and if she wants to "make production" and get her promotions, it's better that she can't fool around. Also, in this location, she's closer to the center of the unit and she always knows what's happening. On her left sits Joan. She is a level 8, who works very hard and is very dedicated. Joan hopes to be a level 9 soon, but then she will no longer be a claims processor; she will become a claims technician or an assistant supervisor. On Ariel's right sits Annette, a level 5 who is having some difficulty and has been placed on warning for a while. Level 5 is the first level at which you are no longer a trainee. Ariel thinks that Annette will most likely be fired soon because her warning has already been extended and she's still having trouble.
Like every desk around, Ariel's is cluttered with the paraphernalia of claims processors. She has organized her small space into an efficient place for doing her work, but she has been careful to leave some room for enough personal objects to make the space her own, including a plant and a photo of her boyfriend and her dog.
As Ariel walks toward her desk, she ignores the two phone messages standing on her keyboard. She also ignores the pile of claims that someone has placed beside her keyboard for her to work through. Instead she immediately notes two claims covered with pink batch sheets: two "voids." Shit! Two more voids with only two days left this week. "Here goes my quality!" she exclaims. It will take a lot of luck if she is to make up for them and maintain the weekly percentage of correct claims she needs. She hates voids; they are frustrating and humiliating. Not only do they mean a lower quality rating for the week in which they occur, but they also mean more work because they have to be processed again.
She takes a look at the first void. She reimbursed lab charges at the regular rate of 85%, but the quality reviewer claims that these charges were related to outpatient surgery, which the plan reimburses at 100%, and should therefore have been reimbursed at 100% as well. She must check this up. She sits down, pushes papers aside, and starts logging into the system. "What a way to start the day!" she complains to Annette.
She enters her operator number and her password. They are strict about security. You are even supposed to log out if you are away from your desk for a short time, but no one really does it. Ariel has heard through the grapevine that there have been cases of embezzlement in the past, that some people have been fired, but nobody seems to know the details.
When the initial working screen comes up, she enters the control number of the employer contract and the social security number of the employee. Then she inspects the patient's claim history. Quality review was right, the current lab charges were related to a surgery that had been the object of a previous claim. She should have caught that: there is no way out. She will not try to dispute this void. She quickly reprocesses the claim.
Then she takes a look at the second void. What? But the patient was seen for headaches. And neurological exams for headaches are considered medical, even if there is a secondary psychological diagnosis.
Therefore the "psych" maximum does not apply. She had actually discussed this case with Nancy and Sheila. She even talked with Maureen, the back-up trainer, who helps people with difficult cases and had agreed with her conclusion. She goes over to show her the void, gets some comforting grumbling about people in the quality review unit, comes back to her desk, pulls out a dispute form from her drawer, and starts filling it out, explaining in detail how she came to her decision. She states emphatically that the back-up trainer had confirmed her determination. Then she goes to her supervisor, who must sign a dispute form before it is submitted to quality review. The supervisor shakes her head in solidarity. Ariel is now quite confident that she will be able to resolve this one in her favor. What a relief!
Now that she has taken care of her voids, Ariel reads her phone messages, and puts them in a tray on her left. She will take care of that in the afternoon. Then she starts looking through the other claims that were sitting on her desk. Lots of "junk claims," as the complicated claims that will require much work are called. Ariel is well organized. '~You have to be, in this job," she always says. What she tries to do is process easy claims fast during the morning and early afternoon and so get her "production" out of the way. Once she has reached her daily quota, she uses the last few hours of the day to take care of "junk" claims and to make phone calls.
Quickly, she flips through her piles of claims and separates the ones she will process this morning. Of course, you never really know just by looking at the claim how involved it is going to be, because there can be surprises when you open the customer's file on the system. But with some experience, you have a pretty good idea at first sight about how difficult a claim is likely to be. Usually, Ariel does this sorting before leaving so that her pile is ready for the next day, but yesterday she was held up by a lady who had gotten divorced and who wanted to know why her claims were no longer being paid. That lady was pretty upset because Ariel was supposed to protect the privacy of Alinsu's customer and thus could not disclose the reason for which her claims were being denied. She could only tell her that she had to talk about this with her ex-husband. After a long struggle, Ariel put the person on hold, just to take a breath. She was so angry, her body was shaking. She ended up transferring the call to her supervisor because the conversation was deteriorating fast.
Ariel starts on her first claim. There is an office visit, a series of tests, and some drug bills. Nothing too complicated. She removes the staples and glues the drug bills on blank sheets to keep them together. Next she goes into the database to check that the employee is on file and that the dates of service on the bills fall after the employee's "effective date" -and before termination, if there is any termination date. There are a number of codes to look for: the branch in the client company, the status code of the employee to make sure that the dependents are covered, and some other codes that, if present, would make this claim complicated. But everything checks out fine: she can start processing.
First, she has to enter the social security number and the name again to select the file for processing. Because a claim has to be paid under the plan governing the period during which the charges were incurred, the computer displays the dates of successive plan changes. She chooses the most recent plan change, since this claim is recent. On the next screen, she has to enter the year the claim is for and the date the claim was received, which was stamped in red by the clerical employee who opened the mail. It is easy to forget to do that because the system enters by default the date of the last claim processed. She ignores a number of caution messages and moves on to the next screen where she checks the address. It is important to make sure the address is correct so the check will reach its destination properly. You will definitely get a void if the address is wrong, even the ZIP code. Next, she selects the customer '5 son as the patient from a list of dependents. She is careful because it is easy to choose the wrong dependent; she got voided for this last month. She makes sure the son is under the age of 19. He is not, but there is a recent note from Patty on his file that he is a full-time student. Patty must have investigated it. She is reliable. But Ariel is bored and she wants to stand up, so she looks over the partition and asks any-way: "Hey, Patty, if you put a full-time student note on a dependent file, does that mean you investigated it?" "You bet," says Patty. No need to confirm the student status.
She now comes to the "paylines," the screen on which she will enter information about the charges so that benefits can be calculated. She starts with the office visit. She enters first the type of service, then the name of the service provider, which leads her into the providers file:
there she makes sure she checks that the provider's address is correct since the insured has "assigned" the benefits to be disbursed directly to the doctor. Then she enters the date of service and the charges. In this case, she must also enter a deduction because the provider happens to have a special contract with Alinsu. She uses a calculation sheet to figure out what the deduction is, looking up the standard charge for this type of office visit in a ring binder, entering the amount on her calculator to compute a reduction of 15%, and choosing the larger amount of the two. It has occurred to her that it would be more advantageous for Alinsu to take the smaller one, but the procedure says to take the larger one.
Oh, no! Not again. She does not want to listen once more to Annette's plans to go to Richland Hot Springs this weekend. What's the big deal with that mud bath? Is she afraid, or what?
Since the patient went to such a "preferred" doctor, Ariel must remember to increase the rate of reimbursement from 80% to 85%. But this means that she will have to split the claim in two since the other charges are to be reimbursed at 80% and cannot be included in this payment. She likes the idea of having this claim generate two "batches" that will count toward her production: after spending all this time on that silly void, she can use a bit of luck. But she quickly checks in the providers file that the lab where the tests were performed does not have a similar contract. You will get in trouble for splitting claims unnecessarily.
The rest of the claim goes fairly fast: enter the code for the diagnosis, for the contract type, skip the coordination section, indicate the assignment of benefits. Remember to include two pattern paragraphs, which are pre-stored explanations you get the system to include with the check: one for the special deduction and one for the deductible, which the system has automatically taken into account.
Ariel types and writes impressively fast. Her eyes scan computer screens quickly, knowing what to look for. Check everything on this last screen and press enter. Then Ariel gets a new claim for the lab charges and for the drug bills. She has to check that a drug she does not remember having seen before is an acceptable prescription drug. Joan says that it's OK with any circulatory condition. The vitamins, of course, have to be denied. All standard stuff. She collects the papers for the two claims, attaches them with paper clips, places them in her outgoing bin, and circles two numbers on the sheet on which she keeps track of her work.
At half past eight, the supervisor comes around to distribute paychecks: consecrated wafers swallowed into expectant rows of purses. She also reminds everyone of the unit meeting to be held at 9:00, and asks who is going to do overtime this Saturday. Ariel will certainly be there, in the morning at least. She can use the money, and on Saturdays there are no phones; you can catch up on production.
Presently, Ariel's phone is ringing: once, twice. She reluctantly grabs the handset. While she talks, however, she does not interrupt her work immediately, but holds the phone with her shoulder and keeps processing the current claim.
Thanks for calling Alinsu Insurance Company. Can I help ...
--Yes, I would like to know what's happening with my claim.
When did you submit it?
I sent it more than a month ago.
Now Ariel realizes that she will need to access information to answer this person's question and that she will not be able to finish the claim she is currently processing before having to do so. She will have to "clear" out of this claim and thus lose all the information she has already entered. This stupid system, you have to lose all your work every time you are interrupted, and that's pretty often. She resigns herself, clears out, and starts typing the access information as her interlocutor gives it to her. The caller does not know the company's control number. "I can look it up for you."
Ariel muffles the phone and turns to Annette. "What's the control number of ZollePro?" she asks. "I don't know, 211 something." Ariel flips through her binder and enters the control number of the company. "It's 21131," she informs Annette. The phone conversation continues for a while, sometimes testing Ariel's patience. There is a backlog; what can she do about it? And it's not her fault if there is no way that clerical can log the receipt of submitted claims into the system. Finally, the caller hangs up. "That guy, he just wouldn't let me go," Ariel complains to Annette. "I know," Annette replies, "as if we had nothing better to do."
At 9:00, the claims processors converge on the supervisor's desk for a unit meeting. They roll their chairs and sit in a semicircle around her desk. Postures vary, ranging from straight backs to leaning over a desk nearby. Most processors sit cross-legged with their notebooks on their laps. Ariel looks at the familiar faces of her colleagues. It has been only a little over a year, and yet so much has happened. So many conversations, so many events. Of course, people get petty around the office. They have nothing better to do. Everybody is here, and it's a matter of interest. You come and you work here eight hours a day. It's your life. People know everything that's going on. They do it out of boredom, she thinks to herself
There is a mixture of local chat with interjections across the semicircle. The atmosphere is generally relaxed and the talking as well as the configuration convey a sense of familiar conviviality. These meetings are a regular occurrence in the office. They take place at least once a month, but usually at shorter intervals - whenever there is business to discuss. Harriet, the supervisor, checks that everyone is there. Esther is still on the phone. "We'll wait for her." There she comes on her chair: after some shuffling and scooting, everyone is ready.
First Harriet reminds everyone of the visit of some important clients and asks processors to clean their desks and to make sure they do not fool around while the visitors are present. Then she announces that she has the vacation list and that she wants people to fill it out. The list is ordered by seniority. Harriet is at the top, and she has already filled her slot out. The list will go around the office in the order in which it is printed, and nobody can be skipped.
There is a problem with the toll-free 800 number that Alinsu customers can call to get information. Management has a suspicion that this number was given out by some processors to their acquaintances as a way of calling them free of charge. From now on, all phone calls exceeding fifteen minutes will be marked. Harriet senses the tension that her remark has brought into the meeting and is quick to clarify that the marking of these phone calls does not in itself constitute an accusation. It is only if patterns develop that an investigation will result. Still the subject seems delicate, and there is some grumbling and a few defensive remarks.
Then they discuss the idea of creating a phone unit within the unit. The gist is that at all times only a few processors would take all incoming phone calls and that people would take turns handling the phones. They have not yet figured out how to do that. Harriet asks for suggestions and requests that processors think about how they would want to go about implementing such an idea. Ariel, like all the processors she talked to, is not even quite sure that she wants a phone unit at all. She is rather ambivalent about phone calls. She sees them as interruptions, either welcome or unwelcome depending on circumstances. She certainly perceives them as obstacles to production. Sometimes she spends as much as half her time on the phone. They disturb her peace and can be a real pain when customers are nasty. But they also break the routine. And having to answer the phone allows her to receive private calls without drawing attention to herself
The next item on the agenda is a memo that modifies the codes that processors are supposed to use to indicate the types of service rendered by providers. Harriet goes through the memo with the processors, paraphrasing each item and letting them ask questions. The change is substantial because these codes are used very frequently, but it is received rather casually by everyone: just another change, another "improvement" that will complicate their work only very slightly. The change will take effect on Monday, after the new version of the system has been installed. On this job, if you can't take change, forget it.
Harriet then asks the processors if they have any items of business to bring up. The assistant supervisor complains that there have been too many overpayments lately. She blames it on the fact that processors do not check eligibility carefully enough. Nancy reminds everyone that they cannot keep paying for physical therapy for a long time, even with a new prescription from a doctor. They must have a progress report. And if physical therapy goes on for more than a year, it has to be referred to the technical unit. Finally, Beliza says, "Well, for me, it's just this deductible." Everyone understands what she is talking about. Certain plans stipulate a complicated way of determining when a family deductible is satisfied. An animated discussion ensues with everyone contributing examples and partial explanations until Beliza seems satisfied:
"It's easy to explain here, but it's a pain to explain it on the phone," she says. Many processors nod.
Last Sunday was the birthday of Sara, the assistant supervisor. A half-sheet birthday cake is placed on her desk, along with a small present from the unit. Even little events like this make the place more enjoyable, like the potluck on Valentine's Day, or the Christmas party. And on Halloween, it's hard to believe you are in an office, with decorations everywhere, competitions for the best unit and the best costumes, parade, and prizes. But Ariel's favorite remains "Kringeling." For a week before Christmas, people put little presents on each other's desks every day, and you have to guess who is putting them on your desk. People get so elaborate - scheming, misleading, guessing, tricking, faking, trading information. Then you realize how well people know each other. Last year, Ariel was able to eliminate all but four candidates because she got a sophisticated note produced on the computer system, and she knew that only four people could do that.
Now Sara blows the candle and starts cutting the cake, and the whole unit applauds and cheers. She and Trish distribute pieces. These cakes are a nice break from the daily routine, but the frosting is always much too thick. Ariel got a corner piece with close to a half-inch coat of white sugary fat on three sides. Before Ariel can complete her eating duties, however, the supervisor says: "Well, it was nice seeing all your faces again." Ariel complies with this invitation to return to processing, taking her piece of cake with her.
The meeting and the cake-cutting ceremony have lasted 45 minutes and Joan wonders whether the cake-cutting part of the meeting must be considered morning break. There is some discreet talk about the issue, but the question is never posed directly to the supervisor. Along with everyone, Ariel decides to assume that this did not count as a break and to see what happens. At a quarter past ten, she leaves for the lounge with Joan, where they spend most of their ten minutes discussing Trish's use of her sister's driver's license to get into a bar last Saturday and her fright when there was a check-up. Lucky she and her sister look alike. As they come down the spiral stair to return to their desks, Ariel reminisces about her own escapades. At her desk, she logs back into the system and starts processing. After a while she adds, without actually turning to Joan, "One good thing about being over 21 is you don't have to deal with this anymore." Two easy claims, two circles in quick succession. Joan has been thinking about Ariel's remark on being over 21, and says: "But then, you know, there are so many other things to worry about."
A few minutes before eleven, Beliza comes by Ariel's desk and asks what she wants for lunch because she is getting ready to call the deli. It's a bit cheaper and there is less waiting when one orders in advance; and since they have only a half hour for lunch, they do not have much time to spare. Still, thinks Ariel, it's better to have a short lunch break and get out earlier. "A ham sandwich with everything on it."
As she circles the code numbers of her processed claim on her "circle sheet," she does a little calculation on the side to figure out how close she is to her hourly quota. Today is going well, not like yesterday.
Now there is no TIN (taxpayer information number) for this doctor. Why can't they just fill out these forms completely? Ariel has to send a letter requesting the information: this means clearing out of the claim and putting it on the paper tray where she keeps claims awaiting further information. Five or six years ago, she heard, they could simply call the doctor's office, but now it is necessary to have all this in writing. She pulls out a form from her drawer and fills out a request to send a form letter. Annette wants to know if she can assume that the date of emergency room treatment is the date of the accident when the patient did not enter the accident date. Ariel is not sure: accident dates are important because of temporary supplemental benefits for accidents on certain plans. Joan says that she always assumes the dates are the same and that she's never been voided on it.
Ariel is processing a claim for which there is a suspicion of a preexisting condition. On the computer, she flips through the claim history to get an idea of how this has been handled so far. The plan has a $2,000 waiver limit on expenses for pre-existing conditions, and the expenses related to this condition amount to only $384 so far, so she need not investigate it. An investigation is started only when the related expenses approach the limit. It is one of those things where it is understood that just nobody does it. Good. Investigating a "pre-exist" can become quite involved, with numerous letters and phone calls. In this case, she pays the claim and enters a claim note stating how much has been paid out of the limit so far. In this office, some people are good about notes and some are not. For instance, every time you change an address - something Ariel has already done three times today - you are supposed to enter a note to that effect, with the date and the source of the new address, so that if another processor later receives an old claim dating before the change, that processor will not put the old address back in. Because not everybody does it, it causes trouble for other people. Ariel is quite diligent about notes herself, but with notes you have to know whom to trust.
Suddenly, Trish asks behind the partition: "Maureen, do you know what's 'incompetent cervix'? The insured put this as a justification of ultrasound." Maureen replies: "I'm pretty sure that it's eligible, but we should have this from the doctor, not just the insured." Ariel wonders what an incompetent cervix might be. It sounds pretty bad. And Maureen's reply, if adequate for the present purpose, is not exactly instructive. There is a lot of medical terminology in claims processing. In training, they had this course on medical terms with all the Greek roots, but she never learned anything from it. Now that she's been on the floor for a while, she knows quite a bit. When she goes to the doctor, she can tell. Of course, she doesn't show it, because her own understanding is not really medical. It is just processing claims. Like this cervix. That's right, that is what an incompetent cervix is: it's eligible. She does not ask Maureen.
It's noon. Beliza goes around to gather the lunch group. Ariel looks at her circle sheet to see how many claims she has processed so far. She counts twenty-two, not including the void she re-entered since these do not count as production. She is on schedule, but she might have to skip her afternoon break. Ariel, Beliza, Sandra, Eric, and Ruth take the elevator down to the deli on the ground floor. Sandra is worried about her quality, which has been in the eighties lately. It's supposed to be above 95%.
The deli's modest furnishings are in sharp contrast with the style of the building. The first time Ariel left the lush decor of the lobby through a small door in the corner to the right of the elevator shaft, she remembers being surprised. She had expected a nice cafe with a full array of delicatessen refinements. Instead she had found herself in a small, poorly lit room, with a few homely, dark brown tables and chairs and a TV on in a corner. The counter offered a simple menu of cafeteria food, and the walls were covered with shelves of food items in truckstop style. But on reflection, she likes it that way now because at least it is affordable. She sometimes smiles at the thought that this deli, cooped in a corner of a building whose style reflects the tastes of cosmopolitan executives and the means of her mammoth employer, is very much like her.
After getting their orders, they all sit around a table. Beliza reassures Sandra that her quality won't affect her pay until she is put on warning. When Sandra expresses her surprise that this has not happened yet, Ariel asks her, "Do you want us to tell them to put you on warning?" They all laugh. "That was a pretty quick morning," Eric comments. Ariel agrees: "Yeah, a unit meeting always helps." They fall silent for a while, enjoying the time perhaps as much as the food.
The conversation resumes. Quality is a problem with the whole unit. That's why the idea of a phone unit has been raised. With all these phone interruptions, it is easy to make careless mistakes. Eric does not know whether he would like to be just on phones for a whole week. And what would they do when there are too many calls at the same time? And now they are going to monitor long calls! Everyone knows that there are business calls that are long. Beliza reminds everyone of that 45-minute phone call that drove her crazy. Surely "they" will recognize that this is unfair.
Ruth mentions the storm that is expected for tonight. So Beliza starts telling a story about her adventure during that terrible flood a few years back. Her husband was sure that the road was safe and that the water was shallow, and he drove on. But suddenly the car started to sink and water started to ooze in from every crack. They had to get out through the windows and climb on the roof Her husband had to jump into the water and wade through it to get some help. The AAA officer was teasing her husband with mocking skepticism until he saw the car and realized that he was going to have to dive into this water to hook the car up and get it out. Mind you, the car started before the incredulous eyes of all onlookers. Beliza always comes up with these amazing stories. But it is time to go back.
As the group reaches the office, they see a gorgeous flower arrangement on Harriet's desk. Since she is out to lunch, they get the story from Trish that her husband had forgotten their anniversary yesterday and was really sorry about it. To send all these flowers like that, he must have been. Ariel notices that Joan's desk is all clean. She remembers the visitors and gets her desk in some order. In her mail bin she has found a response to an inquiry she had sent to technical. "This guy's gonna yell at me." Joan asks her who that is and she reminds her of the case.
His wife's deductible is not transferable from one employer to another.
Make sure vou tell him about the three-month carrv over. That will make him feel better.
This guy's a kid.
He can't get too mad.
He works in the warehouse or something.
When Harriet comes back from lunch, she hands Ariel the response from quality review on her void dispute. Her judgment has been accepted as valid. Good! In spite of her weight concern and the morning cake, Ariel allows herself to take a piece of chocolate from the jar on Harriet's desk. It's hard to resist when that jar is always there, tempting you. And Roberta, a level 8, has taken it upon herself to be the snack provider for the whole unit. She keeps a stock of goods, from candy bars to chewing gum, even Band-AidsŪ. She says that processors are kids and need to be kept happy.
Back to work. On an ambulance claim, Ariel does not see a diagnosis. She goes over to Nancy, who tells her to find one that would do in the patient's claim history. Just anything that will do? Well, she is right, you've got to keep processing moving, keep the cost per claim down, but this is the kind of shortcut you never get in training. Without them, there is no way the job could be done. Ariel's face must have revealed her thoughts, because Nancy just reassures her with a friendly smirk:
"Welcome to claims processing!"
In training, everything looks so strict and black-and-white. But on the floor, everybody learns the shortcuts in order to meet production. For instance, in training, you are taught to start a claim by filling out the forms that will serve as cover sheets for microfilmed records. Yet much of the information on the cover sheet is never used and is redundant with the attached claim record. So experienced processors do not fill out the form completely; they wait until they have completed the entire claim. When they hit the key that indicates they are done, the computer system gives them a batch number. If the number ends with a D, no problem, it will just get paid and archived. If the number ends with a Q, the claim must be sent to quality review, and so you quickly complete the cover sheet. Everyone learns to do that within the first few weeks after moving to the floor.
You are good at claims processing when you can quickly find legitimate ways to get the charges reimbursed to a reasonable extent. You have to choose procedure codes for medical treatment that will allow enough coverage. You have to develop a good sense of how much is reasonable, juggling the whole thing to produce quickly a reasonable story. What makes a story "reasonable" can't be taught during the training class. Even her instructors acknowledged that trainees had to learn it "the right way" for now but that, once they got to the floor, they would learn the shortcuts.
But the shortcuts are not always good for the company or the customer. For instance, Alinsu has a rule that, if a completed claim comes out as a "Q," recalling that claim to make a change will count as a void, that is, as an error on the processor's quality rating. Of course, if you could just recall your Qs, you would process everything super fast, and then quickly recall your Qs to check them carefully. They want you to pay the same attention to every claim. So what people learn to do is that if you notice a mistake on a Q claim after completing it and sending it in, it is better just to let it go, because then there is a chance that the quality reviewer will overlook the error. An error that is discovered outside the internal review process - say, through a complaint by a customer - does not count against you.
Now this claim looks like a duplicate, but Ariel can't tell from the claim history on-line; she needs to check the original bill to see if the services covered are really the same. She goes to the microfilm reader, but the claim was recent and the film has not yet come back from the lab. So Ariel has to fill out a request for clerical to get a copy of the original bill on paper. She clears out of the claim and puts it aside. She'll have to start over when she gets the answer. From across the walkway, Beliza asks, "Transco is 'end of the month' or 'date of termination'?" She wants to know whether a Transco employee who leaves the job is still covered until the end of that month. Some companies do that, some don't. Annette replies, "I think it's 'end of the month'." But Joan corrects her, "No, they just changed it. It was in a memo last week." Ariel overhears the conversation and makes a mental note.
The four visitors announced in the morning have arrived, and they come toward Ariel's unit. Kathryn, the assistant manager, and Roger, from technical, are giving them a tour. There is also someone from the home office, who has been here before to talk with the office manager, but Ariel does not even know who he is. She knows so little about the home office. The visitors are important clients who represent a large case with over 20,000 "lives." The office looks pretty good. Ariel can't hear what the touring group is talking about, and she does not try. She is, for a moment, struck by the way they walk, slowly, with assurance and enduring smiles. She notices their sweeping gazes and their wide gestures as they stroll around the office, discussing, pointing, laughing, nodding. There is a managerial elegance about the way they look at the landscape of her working world. She thinks fleetingly of long distances, of airports and car phones, of meeting rooms and signatures, of statistics and charts. The visitors and their guides pass by Ariel's desk, otherworldly beings gliding through the aisles. Ariel stoops over her work, her knuckles busy with their staccato on her keyboard, her gaze intently scanning characters on her screen, her spirit huddled over the partitioned field of her desk space. Suddenly, the gliding is interrupted. One of the visitors, the benefit representative, has just recognized Beliza's nameplate. They have talked on the phone quite often, but have never met face to face. Beliza stands up politely. "Nice to meet you." They shake hands and exchange a few giggling words; they are colleagues. Then Beliza sits down, and the group glides on.
The afternoon drags on for Ariel. On this job, hours sometimes go by astonishingly fast, in busy chunks between breaks, but sometimes excruciatingly slow, in a trickle of restless minutes. Ariel is a bit tired and wants to go home. The morning moves easier, usually, but the afternoon is always a letdown. After lunch is the hardest time. But it usually builds up after the afternoon break, until it bursts out at 4:00 - to the elevator, to the parking lot, and back in your very own car. Today, Ariel will not take her afternoon break and will stay until ten past four. She looks up. Round and white, above the supervisor's desk, the flat, eyeless face of the clock presides over the day, supervising even the super-visor. "God, why is it so slow this afternoon," Joan complains. Ariel nods in agreement.
Five more easy claims before she will start processing her "junk" and taking care of other business until it's time for her to leave. What I need is a weekend, thinks Ariel. The weekend is always there. It's not like the clock. It doesn't regulate production demands. But it gives each day of the week a slightly different feel. It animates conversations with its escapades, past and future. Ariel decides that she will definitely work only half the day on Saturday.
"I already made production," Ariel says triumphantly as she draws her thirty-seventh circle. Having reached production early is something worth announcing to your neighbors. As the day wears on, the afternoon can become a racing stretch or a coasting respite. She thinks of asking Roberta for one of those little candy bars. No, she better not. She quickly opens her mail and makes a few phone calls, including one to her boyfriend. "See you tomorrow." Joan gets to leave at 3:00.
Now Ariel turns to her pile of junk claims, but she is interrupted by Ruth, who comes over, "Can you take a look at my screen?" "What did I do?" asks Ariel. "I can't understand your note," explains Ruth. Ariel goes over to her desk, looks at the note and clarifies the information she had entered about an adopted child.
Back at her desk, Ariel processes her first junk claim. It takes about 25 minutes. When she presses the key to send the claim in, it turns out to be a "Q" Ariel does not know the exact system that allocates Qs. She believes that they are allocated on a somewhat random basis but that certain plans have a higher percentage of them. She does not know exactly to what degree the appearance of a Q is determined by the type of claim being processed or by the way that she is processing it, but she heard that her supervisor can manipulate the system to send specific claims to quality review. Ariel has been getting a greater number of Qs than usual. As she gets this one, she complains aloud: "What? Another Q? That's terrible! I just spent 25 minutes on this claim!" No one says anything. She does not like to get Qs. Sara did explain to her that having a large number of claims reviewed is good, since each error then accounts for a smaller percentage. Still, you never like to have your work checked, especially after spending so much time on it. Well, back to some junk.
It is ten to four; Ariel will be leaving in 20 minutes. She decides to stop dealing with her junk and to prepare her work for tomorrow. She goes to Sara, the assistant supervisor, to ask her for some work. When claims arrive at Alinsu, they are opened by the clerical unit and sorted by plans. Large plans result in homogeneous piles and small plans are gathered in mixed piles. Ariel pleads for an easy pile, reminding Sara of the difficult work she did in the beginning of the week. Sara gives her a pile from the City Hall. That's an easy plan. Ariel thanks her: tomorrow she will be able to make production early and then catch up on her junk. She returns to her desk and prepares the pile for the morning. Only a few foreseeable problems.
Five past four: it is time to leave. Ariel has processed 41 claims, 17 of which were completely routine, 20 of which she perceived as involving some difficulty or complication, and 4 of which were junk. She answered 26 phone calls, 7 of which were unpleasant. She initiated 9 calls, 5 of which required follow-up and 2 of which involved an uncooperative interlocutor. She fills out her production report: "How much time can we write off for the meeting today?" "Forty-five minutes." She quickly clears her desk, grabs her purse and her coat. "Don't forget that on-hand reports are due today," Annette reminds her. Oh, right, she had almost forgotten. She sits down and starts counting the numbers of unprocessed claims she has in various piles on her desk. They need to know how old the claims are. It's already twenty past four when she is done. Poor Annette, she will still be here for a while, struggling to make production. Why doesn't she quit? Ariel guesses that it's hard to accept that you can't do something. She rushes to Harriet's desk to sign off.
What a crowd waiting for the elevator at this late hour! Ariel tells Lisa that she was right about that deductible being carried over. Lisa replies that it was just her guess. The conversation continues into the elevator. Is her brother still going out with Shirley? She had heard they broke up. Oh, they are still together. Good for them. The elevator reaches the lobby and the contained crowd gushes out. Did she know that Norma Wong was quitting after ten years? Really? Yes, she had found a new job with Casus Casualties. They had asked her how much she was making. She lied and they offered her even more. Not bad! In the lobby, some processors become quiet and some of them talk until they reach the door. But as they spread through the parking lot, they fall silent on their eager way home.
The freeway is already a bit slow. Toward the city, Ariel looks at the brownish haze of smog hanging over the hills: the sky looks like it has dragged the hem of its bright evening gown in the dust. The thing is, it only seems to be getting worse. Pollution really worries her. What about cancer? There was that old lady whose husband was dying of lung cancer and who called her three times to ask the same question about hospital deductibles. What is going to happen? Ariel would even pay a bit more for gas if she knew it would help. But it would probably go into someone's pocket. As she turns on the radio and starts tapping the beat on her steering wheel, she thinks of the computer system she uses, of the new one to be installed soon that is supposed to do so much more, of the elevator that talks to you. Pollution? "Well, I'm sure they'll figure out something."