Wellfleet Student plans are designed with the goal of member satisfaction, by delivering the right care at 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, we have a passionate internal team that works tirelessly for our members. This includes customer service, a quality assurance department, and a clinical department, with oversight from our Chief Medical Officer.
A key tenet of our quality assurance is our responsibility to monitor and control costs so that we can help reduce the expenses for our clients and members. We negotiate with our partners to help with this, and much of the savings are established before a member ever seeks service. So, to aid in cost containment for members, the plan and providers, we also monitor claims activity.
Knowing the importance of monitoring claims activity, we only automate 20 percent of the claims submissions we receive. In order to take on this work, we utilize in-house and external resources to review claims submissions. We’re happy to report that many of the bills that come to us align with the diagnosis and treatment the member received. However, each month, we can see up to $20,000 in improper bill coding. If this wasn’t caught by our vigilant staff, it could cost members upwards of $3,000 out-of-pocket!
Case study: Impacts of claim monitoring
In the spring of 2020, there was a case with medical coding that didn’t line up. Welcoming a child into the world is an experience for current and to-be parents that is like no other. Sure, there’s some anxiety, but with it comes a sense of joy and wonder for the magical moments that are to come.
Pure joy is what one student member was experiencing after welcoming her baby girl to world. However, there was a small cause for concern. Not because she had given birth to a premature baby, approximately six weeks early. Rather, at two weeks of age, the baby was diagnosed with endocarditis, a potentially life-threatening infection of the heart muscle.
Endocarditis is caused by bacteria entering the patient’s bloodstream from an outside source. In the case of a newborn, this would be through a non-sterile catheter or IV line. This is considered a Hospital Acquired Condition (HAC) or an event that should not have occurred and is often preventable based on existing evidence. In almost all cases, it is the financial responsibility of the facility, not the insurer or the patient.
The hospital staff took every precaution to care for the child and keep mom at ease once the condition was identified. Then, eleven days before discharge, the baby was transferred to a lower level of care. This was because the baby was medically stable, other than the need to receive IV antibiotics. In total, the baby spent more than six weeks in the hospital. And 11 of those days were directly related to observation after the HAC.
When Wellfleet’s Medical Management team reviewed the case, they found the plan and the member would be charged for those 11 days. The team denied paying for charges incurred for those last 11 days, because they were directly related to the HAC. This careful review helped save the member more than $6,000 in co-insurance and saved the plan more than $66,000.
Learn more about Wellfleet Student’s commitment to our clients and member.