Wellfleet’s amazing out-of-network claims negotiation

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.

Collaborative efforts drive change

When a high-dollar claim is received at Wellfleet, several teams step into action to identify ways to help the member. The Payment Integrity, Claims, Clinical and Provider teams collaborate to identify the billed charges, the codes billed, the underlying circumstances of the claim, and the financial impact to the member and the plan. Once those items are identified and criteria is met, the Provider Network team will contact the provider to work toward a negotiated settlement on behalf of the school or group.

We are pleased to report that 99 percent of providers we contact, agree to work with us to negotiate the charges, which can generate significant savings for the member and the plan.

Case study: Impacts of negotiated settlements

The college years are an exciting time for students. Along with building a foundation for their future, they’re building life-long friends and memories.

One of our latest negotiations included a 22-year old student member who was involved in a high-speed motor vehicle accident. Unfortunately, they were an unrestrained passenger, and, during the event, sustained a traumatic brain injury.

The student’s road to recovery started with inpatient care at an acute care facility for several months and included several surgeries. While the facility was an in-network provider, the surgeons who treated the student were out-of-network.

When Wellfleet received the high dollar claims, our internal teams saw how the financial impact could be another devastating blow to the student. So, they took action to contain the overall cost to reduce the financial impact to our member and the plan.

After some due diligence, they contacted the out-of-network provider to negotiate the high dollar claims. While out-of-network providers are not obligated to assist with these requests for negotiation, this provider agreed. The team was able to negotiate a settlement which resulted in an 87 percent overall savings for the member and the school plan.

Through their efforts, the Wellfleet team saved the school plan nearly $500K, while saving the member more than $40,000 in out-of-pocket costs.

While the savings achieved in this study do not represent the outcome of every single case negotiation Wellfleet works on, this study represents one of the recent successes achieved.

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

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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.