Unsupported coding saves student member $2,500!

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 Payment Integrity team

Our Payment Integrity 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.

Unsupported coding

When Wellfleet Student members are planning to start a family, they can be confident in the support they’ll receive. Our plans are built to help cover the expected and the unexpected as parents welcome their newborns to the world.

Recently, a student member gave birth to a baby girl after several hours of labor. Although tiring for mom and baby, the birth took place without any complications. Mom, dad and baby were able to enjoy time together and return home to start their new adventure two days later.

Although the birth went well, the billing that accompanied the event didn’t add up when our payment integrity team began their review. The hospital bill for the baby was a single, all-inclusive payment for the birth of a child with significant problems. The individual diagnoses and procedures that resulted in that bill stated the baby was heavy for gestational age and also experienced meconium staining.

What is meconium staining?

Meconium is a thick, greenish-black substance that forms in a baby’s intestines while ingesting amniotic fluid in the womb. Post birth, it is the first stool the baby will pass. Sometimes, it enters the amniotic fluid prior to birth, and can be noticed after mom’s water breaks or when the baby is born. This is called meconium staining.

Meconium staining illustration
Illustration from

What problems are associated with meconium staining?

Meconium staining by itself is not a problem. If meconium is present during birth, the baby may breathe it into their lungs. This is known as meconium aspiration. This is problematic because the substance is thick and can stick to air sacs in the lungs. When this happens, it is hard for the baby to breathe and can lead to infection or pneumonia.

When meconium staining is noticed, staff will watch for signs of lung problems and may need to take x-rays to check for potential issues. If necessary, staff will start suction procedures to remove the meconium. Most babies will get better within a few days, but some cases of meconium aspiration can lead to death. Fortunately, for our new mom and baby there was only meconium staining (not meconium aspiration), which is not a significant problem.

Final review

Throughout the country, hospitals work with providers to establish standard fees for delivering a baby. However, they may increase that fee when there are complications during or after the birth that increase the amount of care required to manage the baby’s hospitalization. To assure patients are charged appropriately, the government limits what conditions can be used to raise the standard fee for the delivery of a baby.

In this instance, neither the meconium aspiration, nor heavy for gestational age as they were coded on this member’s claim are on the list of conditions the government allows to increase the fees for delivery and care of a newborn baby. Because of this, the payment integrity team worked with the provider to reduce the all-inclusive payment to one for the birth of a normal child.

This finding helped save the student member $2,500 in out-of-pocket fees and saved the school’s plan more than $22,000!

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

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