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Discharge oversight saves client and member thousands

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.

Not satisfied with business as usual

When high-dollar claims come into Wellfleet, there are several internal teams that review to ensure the bill is appropriate for the care provided. There are a few steps in the process to ensure proper evaluation to help 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.

Case study: Out-of-Network scrutiny

A Wellfleet student member developed an infection due to their paraplegia. The member was taken by ambulance to an out-of-network hospital. After nine days in the hospital, the member was discharged and felt much better.

Unfortunately, the member was not aware that they were about to be on the hook for a large and unnecessary out-of-pocket expense because the hospital was out-of-network. That is where the Wellfleet Payment Integrity Team stepped in. When reviewing the claim, the prognosis and treatment were appropriate for the student member. However, the facility’s execution of the member’s care plan was not in the patient’s best interest.

Uncovering discharge oversight

When reviewing the file closer, the Wellfleet team found the treatment to be routine, and without complications. This meant the treatment and discharge would follow a standard timeline. What they found was the facility failed to set up the members discharge planning in a timely manner. Discharge planning should have been set in motion after Day 1 of the treatment but wasn’t initiated until the member’s antibiotic treatment had been completed. The delay led to the member staying at the hospital for another five days and an additional $20,000 fee to the plan.

Wellfleet contacted the out-of-network provider to confirm the events. It was confirmed the correct treatment was provided and that the student should have been discharged five days earlier as home care and medication had been arranged once no clinical issues were found.

Through scrutiny and due diligence, the team was able to save the plan 55 percent of the original charge. This also made the member eligible to save more than $3,000 in unnecessary out-of-pocket expenses.

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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. ©2020 Wellfleet Group, LLC. All Rights Reserved.