Matters of the heart – Ensuring clients and members love their billing outcome

Wellfleet’s student health 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 them. This is to ensure the bill is appropriate for the care provided. The steps in their process ensures proper evaluation, to 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.

Incorrect billing charges

A member had been having minor chest discomfort and scheduled an exam with their physician. After meeting with their physician, it was determined that the discomfort was related to a failing lead in their pacemaker.

Some pacemakers have three leads – or flexible, insulated wires that are placed in a chamber, or chambers of the heart to aid in pumping blood and adjusting heart rate. Sometimes these leads fail due to a loose or broken wire between the pacemaker and the heart, electronic circuit failure or a fracture in the wire. In this instance, the wire needed to be changed.

The member worked with their physician to schedule a surgery to replace the defective lead. They were able to get an in-network appointment and the procedure went off successfully for the member.

However, the claim that was filed by the hospital was incorrect. It listed charges that didn’t align with why the member went in for surgery. The payment integrity team found the plan was being charged for an implant, a pacemaker and new leads. After a thorough investigation, the team confirmed that only the lead was replaced and denied the additional charges.

Their work helped save the plan more than $40,000 and the member more than $4,000 in out-of-pocket fees.

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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.