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 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.
Uncovering charges the member shouldn’t pay
After consulting with their primary care physician about discomfort, it was determined a student member would need to undergo hernia surgery for relief of their symptoms. Fortunately, the student member was quickly able to find a quality, in-network surgeon and scheduled their procedure.
While the procedure was a success, when in recovery, the student member began coughing up blood. Since this was happening during the COVID-19 pandemic, the student member was immediately tested for the COVID-19 Coronavirus. Fortunately, tests came back negative. The hospital staff worked diligently to identify the cause and stop the cough, and the member was able to return home the following day.
Weeks later, the payment integrity team received the billing for the members procedure. When reviewing it, they found that the root cause was a traumatic intubation – or injury to the larynx when inserting a tube to assist with breathing during anesthesia or sedation.
Although this can be viewed as a common occurrence during surgical procedures, here it was found to be egregious. The payment integrity team worked with the provider to remove the expenses related to the injury caused from the intubation. Their attention to detail helped save the member more than $5,000 in out-of-pocket fees!
Learn more about Wellfleet Student’s commitment to our clients and members.
