Our payment integrity program is one that upholds our commitment to the Triple Aim – the right care, at the right price, to our members’ satisfaction – for our clients and members.
With a sharp focus on the Triple Aim, our team is actively involved in verifying all claims received are for eligible members, from legitimate providers, and that Wellfleet is the carrier responsible for payment. This includes ensuring billing is adherent to payment policies, in line with standard medical protocol guidelines, and are not wasteful or abusive.
This proactive approach is one of the many ways Wellfleet Student is different from other student health insurance carriers. With roots as a TPA (Third-party Administrator), we know that every dollar counts. So, we collaborate with our partners to go above and beyond to deliver greater savings for our clients and student members. This helps ensure members are receiving the best pricing for the services they received, while assuring providers are being paid appropriately for services rendered.
Verifying that we’re paying the appropriate amount for services rendered is essential to manage the cost of care for our clients and student members. To do this, Wellfleet has an orchestrated process, using intelligent technology and capable team members to aid in billing and procedure validation.
To ensure the best outcome for our clients, we do our first phase of billing review before it goes to our clients and members. We look at multiple factors, including where the service was provided (in/out-of-network, ER), what service(s) were provided (Ambulance, x-ray, surgery, diagnosis), as well as policy and coding alignment.
We want to make sure that the provider is not billing for a higher level of service than what was actually performed. This is done on both inpatient and outpatient claims.
The collective group of individuals doing the work are known internally as our payment integrity team. Although their work is done behind the scenes, it is their due diligence that has saved clients and members millions of dollars.
In 2020, their work helped save more than $17 million. Further, over the last five years, they’ve helped save more than $58 million!
We also work with our provider network to get the best in- and out-of-network rate possible. However, negotiating out-of-network charges can be challenging. That’s why we have a dedicated team that works with providers countrywide to obtain discounts for the services rendered. Using aggregated, anonymized data they’re able to identify appropriate rates to pay based on condition and services provided.
In 2020 alone, our efforts help reduce total out-of-network expenses for clients and members by $7.8 million.
In addition to our pre-payment bill review, every month we do a post-payment analysis. This is all part of our constant improvement process, as well as our commitment to member savings. Because our database is constantly growing, we have the potential to uncover trends that may not have been apparent at the initial review. If we find items that should have been addressed, we’ll follow up with our providers to reconcile. We then provide credits back to our clients and update our process to prevent reoccurrence.
In 2020, our efforts in post-payment reconciliation reduced total out-of-network expenses and by more than $264,000.
Waste and abuse
Another area of our billing analysis pertains to errors, waste and abuse. This review involves detailed analysis of claims by provider and type of service. So here, systems are leveraging aggregate data and established guidelines to compare typical procedures and outcomes for a particular provider.
If outliers are identified, there is a deeper dive to uncover the ‘why’. Once the reason is established, action is taken to approve or deny the claim. On certain denials, there is follow up with the provider to help educate and ensure smoother interactions on future cases.
In 2020, this program saved clients and members more than $183,000.
Continuous improvement of the payment integrity program
In thinking of what’s best for the clients and their members, we revisited our payment guidelines to identify areas we could update.
One area we investigated was what “standard” really means for “standard procedures”. We found some of the policies were vague and didn’t align with new research and advances in medicine. So, we referenced several industry authorities, including the American Medical Association and updated them. This helped us implement more modern standards to ensure stricter scrutiny and member-friendly outcomes.
An area where we’re constantly evolving is with new procedures. This is because there have been so many great procedural advancements in the last few years. With these advances, there may not be new coding or standards. When these situations arise we scrutinize, because we want to better understand the procedure and pay accordingly. Often, these are positive experiences for us and the provider – because it helps streamline interactions and ensures proper payment across the board.
Member satisfaction – our ‘North Star’
The goal of our payment integrity program is to help control costs for our clients and members. We want to ensure that they are satisfied with the cost of care they are receiving.
We strive to do the most that we can to provide member satisfaction. It’s as simple as that. That’s why we work so hard at building member-focused programs and resources.
Learn more about our member focused programs.