Provider network team finds 6 days of unwarranted fees

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 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.

Case study: Impacts of negotiated settlements

One negotiation included a student member who has a rare but potentially fatal cancer.

The student member was on medications to help with the cancer. While home, they were not feeling well and checked into the hospital. Tests found that the member had a low blood count along with other abnormal lab counts. As a precaution, the hospital admitted the member for further testing and treatment. In total, the student member was in the hospital for 23 days.

When Wellfleet reviewed the bill, the team found that appropriate treatments were provided. However, based on coding and other records, they found the staff stopped administering tests or giving treatment the last six days the student was in the hospital.

Due to the added expense and potential out-of-pocket costs to the member for those last six days, the Wellfleet Provider Team took action. By carefully tracking the patient records, network negotiations, and Medicare standards, they were able to get the charges for the last six days removed.

The team was able to save the school plan more than $30,000, making the student member eligible to save more than $3,000 in out-of-pocket expenses.

Learn more about Wellfleet Student’s commitment to our clients and member.

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