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.
Improper coding for neonatal hypothermia
Year after year, Wellfleet provides coverage for Student members planning for and starting a new family. From prenatal vitamins to emergency C-sections, our plans help provide students with the care they need to support a healthy, growing family. Recently, a student member started their growing family with the birth of a beautiful baby boy. Fortunately, there were no complications during the delivery and mom, dad and baby were able to return home two days later. When reviewing the billing for the birth, our payment integrity team uncovered coding that didn’t correlate to a normal delivery. Of note, was a listing of ‘mild hypothermia of newborn’.
What is neonatal hypothermia?
Mild hypothermia of a newborn or neonatal hypothermia is when a newborn’s body temperature falls below 36.5° C (97.7° F). This is a major concern as neonatal hypothermia increases morbidity and mortality. Hypothermia can be caused by disorders that impair thermoregulation like sepsis, intracranial hemorrhage, drug withdrawal, as well as environmental factors.
Once identified, hypothermic infants should be rewarmed by a radiant warmer or incubator, and investigation for underlying conditions must be diagnosed and treated.
In this case, the cause was purely environmental. The newborn was immediately treated with simple warming techniques, and quickly recovered without any other additional medical issues.
While the hospital was right in noting the newborn was experiencing hypothermia, they incorrectly added coding to indicate that it was caused by something other than the temperature of the delivery room.
Thankfully, the medical records provided full detail that this was a normal, healthy newborn with a brief episode of early hypothermia who responded to warming techniques. Further, after the warming was completed, this episode was not repeated and was determined to be due to “environmental factors.” In other words, it was iatrogenic, or a healthcare acquired condition and did not need any further attention.
With the help of these findings, the payment integrity team worked with the hospital to remove the fees associated with care for a ‘newborn with significant problems’ and adjust to that of a ‘normal delivery’.
This finding helped save the school’s plan more than $35,000 and the student member more than $3,000 in out-of-pocket fees.
Learn more about the Wellfleet Student payment integrity program and how it upholds our commitment to the Triple Aim – the right care, at the right price, to our members’ satisfaction – for our clients and members.