Billing scrutiny uncovers big savings for student

Wellfleet Student plans are designed with the goal of member satisfaction, by delivering the right care, at the right place, for the right price. Through a partnership with Cigna, Wellfleet provides its student members access to more than 900,000 providers at more than 6,000 facilities nationwide. In addition to having a great network partner, we have a passionate internal team that works tirelessly for our members. This includes customer service, a quality assurance department, and provider and clinical team, with oversight from our Chief Medical Officer.

Wellfleet’s Provider Network team

Our Provider Network team works closely with network partners and vendors to ensure our members have access to high quality, in- and out-of-network care. As faithful stewards to our members, the team works with providers on a case-by-case basis, to help reduce their out-of-pocket responsibility and retain cost for the health plan.

Not satisfied with business as usual

When high-dollar claims come into Wellfleet, there are several internal teams that review to ensure the bill is appropriate for the care provided. There are a few steps in the process to ensure proper evaluation to help provide the fairest outcome for the member and the plan. Most times these high-dollar claims are appropriate, and the approval is seen as business as usual. However, some raise flags based on things like billing, coding, or prior treatments.

Improper coding for newborn

Wellfleet is delighted to provide coverage to the scores of student members welcoming new additions to their family each year. We understand the joys and concerns that come with welcoming a newborn. That’s why our payment integrity team always scrutinizes billing to ensure the member has received the right care at the right price.

In this instance, our payment integrity team was determined to ensure a student member was correctly billed for the birth of her child that included procedural codes for Syndrome of infant of mother with gestational diabetes. The billing included respiratory distress, small for gestational age, congenital malformation, hypocalcemia and other factors.

While gestational diabetes is common for expectant mothers, the condition can be treated by eating healthy foods, exercising and, if necessary, taking medication. In reviewing the member’s file, it was noted that diet and exercise helped quell the condition.

Billing correction uncovers savings of more than $36,000

Even with the treatment of mom, the newborn can experience symptoms. So, the team furthered its examination of the file. It uncovered that the newborn had a single early episode of hypoglycemia but responded to appropriate treatment.

While episodes of hypoglycemia are not uncommon in newborns shortly after birth, this newborn wasn’t small for gestational age (birthweight was in the 21st percentile), and did not have other signs, symptoms or treatment related to Syndrome of infant of mother with gestational diabetes.

Due to this and other factors, the team worked with the provider to correct the billing to reflect a normal newborn. With this correction, the team was able to save the plan more than $36,000 or 86 percent of the original charge. Further, this helped the member save more than $3,500 in unnecessary out-of-pocket expenses.

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