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.
Year after year, Wellfleet is honored to help provide coverage for those student members growing their family. From prenatal visits to ultrasounds, to pre- and post-delivery, we help cover the expected and the unexpected as parents welcome their newborns to the world.
That’s why our payment integrity team was caught off-guard when reviewing a bill for a newborn. The bill included procedural codes associated with one member’s baby being small for gestational age (SGA). Not that this is atypical, but rather, it is something that is typically diagnosed prior to birth, and this was the first time it was indicated on the student member’s records
What is small for gestational age?
Small for gestational age is used to describe babies who are smaller than most others of the same gestational age. Babies reach this criteria when their weight is determined to be below the 10th percentile. This is often diagnosed as Intrauterine growth restriction (IUGR), before birth. The chart below tracks the typical trajectory from 36 weeks through post-term, 43 weeks.
Upon further review of the member’s file, it was found that the newborn was slightly underweight, but well above the 10th percentile and did not need or undergo special procedures after their birth. So, the payment integrity team worked with the provider to correct the file and remove the charge for SGA procedures.
This finding helped save the student member almost $4,000 in out-of-pocket fees and saved the school’s plan more than $36,000!
Learn more about Wellfleet Student’s commitment to our clients and members.