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 1 million 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.
Each year, Wellfleet helps provide coverage for many student members giving birth. For us, it’s a joy to play a role in helping the growing family. Knowing that birthing doesn’t always go as planned, we take extra care to ensure our members are satisfied with and charged appropriately for the care they received.
Recently, one student member needed to undergo an emergency cesarean section due to abnormal fetal heart tracings (heart rate and rhythm) due to cord compression while in utero. This is because when the cord is compressed during labor it slows down the flow of blood and oxygen to the baby; see image below. If compressed for a long period of time it can lead to brain damage or even death.
Post-birth there is concern that there could be negative long-term impacts to the newborn. So, hospital staff take measures to ensure proper follow up treatment can be provided. Here, that started with the staff conducting a standard Apgar test to monitor and score breathing, heart rate, reflexes, muscle tone and skin color. Thankfully, the newborn did well and scored a 9 and 9.
Coding correction saves plan more than $66,000
The newborn was admitted to the nursery with routine care and discharged four days later; a typical timeframe for cesarean section births. However, when Wellfleet received the billing, the coding told a story that was anything but standard.
The coding pointed to a newborn with significant problems, which could have applied if there were complications after the delivery. However, upon file scrutiny, it was determined that once the cord compression was relieved by delivery, the cardiac issues immediately resolved. Plus, the member received only “routine care” during their stay. So, the payment integrity team worked with the provider to reduce the all-inclusive payment to one for a normal newborn.
With this correction, the team was able to save the plan more than $66,000. Further, this helped the member save more than $6,000 in unnecessary out-of-pocket expenses.
Learn more about Wellfleet Student’s commitment to our clients and members.