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 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.
Providing coverage for student’s needs – including those that are hard to pronounce
Wellfleet Student plans cover a range of services for our members, from routine to complex. Including those that are complex to pronounce, like orthognathic (or-thog-NATH-ik) surgery – or more simply – jaw surgery.
Orthognathic surgery is a procedure that helps realign the jaw and teeth to improve the way that they work. 1 Some reasons patients typically undergo this surgery to help improve chewing, correct problems with swallowing or speech, improve pain and discomfort, or to improve symmetry.1 This is a procedure that can only take place after growth stops – which is around ages 14 to 16 years for females and ages 17 to 21 years for males. 1
Helping to fix the student member’s jaw and billing
Recently a student member underwent this procedure, to help improve their ability to chew and swallow – something they struggled with for many years. The procedure was a success! After a two day stay in the hospital for recovery and monitoring (which is standard for this procedure), returned home and was in great spirits. Happy ending, right? Not yet.
You see, when the billing came to Wellfleet there was coding that told a story of a more extreme situation while the student was at the hospital, including acute posthemorrhagic anemia. This is a condition that develops when you lose a large amount of blood quickly.2
From here, the payment integrity team examined the notes on the file to confirm the complications. Upon review, the member had no complications during the procedure and was admitted for routine post-operative monitoring. The member did demonstrate down-trending of their hemoglobin, but required no treatment for this other than continued monitoring. Further, the notes never listed “anemia” nor hemorrhage” as a problem to monitor. Further, there was no acute bleeding event and a note stating, “no significant events for the remainder of the admission.”
With this information in hand, the payment integrity team reviewed the claim with the provider to correct the coding. In total this update in coding saved the plan more than $36,000, and the student member more than $3,000 in out-of-pocket fees! There’s the happy ending – que the music and roll the credits.
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1 Mayo Clinic. (n.d.). Jaw surgery. Retrieved on June 2, 2022 from https://www.mayoclinic.org/tests-procedures/jaw-surgery/about/pac-20384990.
2 Drugs.com (2022, May 27). Acute Posthemorrhagic Anemia. Retrieved on June 3, 2022, from https://www.drugs.com/cg/acute-posthemorrhagic-anemia.html.