Wellfleet designs our health plans with students at the forefront, meaning we prioritize their unique needs. One key consideration for students is affordability. With the expense of college, incurring additional costs for healthcare can be a burden on students. Therefore, we build our health plans with low out-of-pocket costs.
Additionally, Wellfleet Student looks closely for ways to save money for schools and students. One of the ways we do this is through claim scrutiny of all high-dollar claims. We review claims closely and check for billing errors. It’s not uncommon for our Payment Integrity team to uncover significant savings for schools and members by fixing an incorrect bill.
In this blog, learn about how our team fixed a billing mistake on a member’s surgery, which led to school plan savings of nearly $40,000 dollars and student savings of $4,000 in out-of-pocket fees!
Finding relief for chronic back pain
A member of our student health insurance plan was experiencing chronic back pain due to scoliosis, a sideways curvature of the spine.1 Scoliosis is generally mild in severity, but patients with the condition can suffer from a variety of complications, including:
- Breathing difficulty
- Chronic back pain
- Noticeable changes in appearance1
Our student member decided to seek medical treatment to help reduce the chronic back pain caused by scoliosis. Working with a quality, in-network doctor, the member was able to discuss symptoms and identify the best treatment for the condition. They agreed on a spinal fusion.
Spinal fusion is a procedure used to connect bones within the spine, which can help alleviate pain.2 Surgery is rarely needed with scoliosis, and it’s generally reserved for patients who have severe curvature of the spine.3
In the surgery, the surgeon places pieces of bone or material like bone between bones in the spine.2 They may also use plates, screws, or rods to connect the bones.2 The goal is to get the bones to fuse and turn into one bone.2
Spinal fusion helps scoliosis because it lessens the curve in the spine and helps prevent future progression.3 Post-surgery, patients generally stay in the hospital for two to three days and then transition to recovery at home.2
The member’s surgery was a success, and they returned home to heal and begin physical therapy.
How our team fixed the billing mistake
A few weeks later, when Wellfleet’s Payment Integrity team received the medical bill, we noticed some discrepancies. Initially, the claim looked fine, but the coding noted complications during surgery.
So, the team began scrutinizing the file and found no abnormalities in the surgical process. Rather, the member underwent a typical surgery and recovery. Upon discussion with the provider, it was determined that complications were added in error, and the provider agreed to remove the additional charges.
The initial amount charged for the procedure was $184,045, but after our team corrected the errors, the billing was reduced to $144,760.
Fixing this mistake translated to a plan savings of $39,285 for the school and resulted in out-of-pocket member savings of $4,000.
Interested in another case study? See how our team saved a member $4,300 in out-of-pocket costs for the birth of a newborn.
How our team saves money on claims
The Wellfleet Student team understands how important affordability is for college students. That’s why we have implemented several strategies that help reduce costs, including:
- Prior authorizations for certain treatments
- Step therapy for many medications
- Low-cost generic medication options
- Low premiums, deductibles, and out-of-pocket maximums
- High-dollar claim review
Learn more about our healthcare cost estimator tool, another way we reduce costs of care for students.
An important way Wellfleet Student provides our members with the best student health insurance at the most affordable cost is through our claims review process. While many health plans approve claims without additional review, we analyze every high-dollar claim we receive to ensure no mistakes or overcharges are present.
When high-dollar claims come into Wellfleet, they undergo an intense multi-tiered review process. Most times, these claims are appropriate, and the approval is seen as business as usual. However, some claims raise red flags based on things like billing, coding, or prior treatments.
If we find a mistake, we review the claim in depth, identify the correct billing for the claim, and work with the provider to come to a resolution.
In addition to saving the member money through reduced out-of-pocket costs, our intense claim scrutiny process often leads to future premium savings. That’s because premium rates depend on the prior year’s plan spend. So, if a school reduces plan spend, this translates to savings in students’ future premium rates.
As a health insurance carrier committed to students, we work hard to keep costs low. Our members deserve care that fits their budget, so we go the extra mile to make that happen.
In this case study, learn how Wellfleet created a tailored network and inclusive care solution for a large university.
Learn more about Wellfleet
Reach out to a Wellfleet representative to learn more about how we can create a student-centric health plan tailored to your students.
References
1 Mayo Clinic staff. (2023, May 13). Scoliosis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/scoliosis/symptoms-causes/syc-20350716.
2 Mayo Clinic staff. (2022, Dec 18). Spinal fusion. Mayo Clinic. https://www.mayoclinic.org/tests-procedures/spinal-fusion/about/pac-20384523.
3 Zawn Villines. (2022, Jan 31). Spinal fusion surgery for scoliosis: What does it involve? Medical News Today. https://www.medicalnewstoday.com/articles/spinal-fusion-surgery-for-scoliosis#is-it-worth-it.
Wellfleet is the marketing name used to refer to the insurance and administrative operations of Wellfleet Insurance Company, Wellfleet New York Insurance Company, and Wellfleet Group, LLC. All insurance products are administered or managed by Wellfleet Group, LLC. Product availability is based upon business and/or regulatory approval and may differ among companies.
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