The Code Catchers

How Select Health Leverages Data and Compliance to Uphold Ethical Standards and Prevent Insurance Fraud

The Centers for Medicare and Medicaid Services (CMS) employ a Risk Adjustment process, which allocates higher payments to plans covering members with complex chronic conditions. These conditions increase the cost of care through higher claims cost, IP utilization, medication, and doctor visits. Unfortunately, this methodology can inadvertently incentivize Health Plans to optimize their diagnostic coding processes to receive higher government payments.

In 2023, Cigna was fined $172 million to sidestep allegations that they were “submitting and failing to withdraw inaccurate and untruthful diagnosis codes for its Medicare Advantage Plan enrollees in order to increase its payments from Medicare,” according to the DOJ.

Select Health serves over 1 million people in Utah, Idaho, Colorado, and Nevada, Select Health is part of Intermountain Health, the largest healthcare provider in the Mountain West.

As VP Risk Adjustment for Select Health, Rebecca Welling oversees the risk adjustment programs for government related lines of business, including Medicare, Medicaid, and the Affordable Care Act. Rebecca oversees a 31-person team whose primary focus is accurate and complete documentation and coding. This spans the entire 360 of a patient’s healthcare experience from the initial Doctor’s appointment to the chart documentation, and finally to the submission of data to the government. There are multiple steps here that must be done in a compliant and ethical workflow. This work also extends to Intermountain Health’s Risk Adjustment policy and workflows. “There’s a lot of fraud in risk adjustment, and we want to ensure Select Health and Intermountain Health maintain the highest ethical standards,” noted Welling.

The nonprofit integrated health system of Intermountain Health and Select Health is driven by a shared mission to make communities better. This combined mission is ensuring their patients and members “live the healthiest lives possible. We want to serve our community, especially the poor and vulnerable.”

Rebecca Welling

Welling’s particular challenge is to ensure that everything that Select Health and Intermountain Health reports to the government are accurate, well documented, and reflect the excellent care members receive.

Risk Adjustment mandates that Select Health must capture the correct disease burden of their members. Accurate documentation is critical to ensure members receive the care they need and that Select Health secures appropriate funding to cover costs. “For instance, if a member with diabetes also has complications like chronic kidney disease or foot ulcers, these conditions must be documented to account for the associated costs and to be compliant with CMS. Failure to do so risks insufficient reimbursement and compromises care,” Welling stated.

To do Risk Adjustment efficiently, they must have good data. This helps target the right people and reduce operational inefficiencies. Part of that good data is an ongoing analysis of the ROI of the risk adjustment programs. Welling’s team leverages robust data analysis to identify potential coding gaps. These tools help verify that diagnoses are properly documented without denying or delaying claims. “For example, if medication records indicate a condition like hemophilia but no corresponding diagnosis code is present, the team proactively collaborates with physicians to determine if correction is needed for the possible oversight. Our focus is on accurate, thorough treatment — not on withholding care,” Welling emphasized.

Select Health also uses new natural language processing technology to help mitigate gaps in care and coding as well as feed into their analytics. This is a technology that reads medical records and highlights potential over- or under-coding in the medical record. Welling commented, “In addition, we must curate multiple data source from State Health exchanges, Medicare return files, and EMR extracts.”

Risk adjustment extends beyond documentation; it’s about fostering real connections between members and their healthcare providers. Select Health prioritizes ensuring every member has a primary care physician (PCP), particularly Medicare enrollees who often require higher levels of care. “We want our members to see their doctor. We want to ensure their care is holistic,” said Welling.

To incentivize preventive care, Select Health offers benefits such as free annual checkups, zero-cost lab tests, and a $100 wellness account reward for members who visit their PCP. Welling noted, “This proactive approach reduces long-term healthcare costs and enables Select Health to offer lower premiums.”

As a nonprofit, Select Health reinvests dollars into member benefits, focusing on affordability and community well-being. This is particularly evident in Utah as a market leader under the Affordable Care Act (ACA). By offering additional plan options, Select Health ensures access to quality insurance for underserved populations. “Our bottom line is proactive, affordable care,” said Welling. “We are here to serve our community, especially underserved and vulnerable communities, with no tricks — just a commitment to ethics, compliance, and access to patient care.”

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Select Health is a nonprofit health plan serving more than a million members. Through a shared mission with Intermountain Healthcare® of Helping People Live the Healthiest Lives Possible®, we are committed to ensuring access to high-value care, providing superior service, and supporting the health of our members and the communities we serve.

In addition to commercial and government medical plans, Select Health offers dental, vision, and pharmacy benefit management coverage to its members. Select Health plans are available for Medicare Advantage and Medicaid enrollees, and we’re also a carrier for the Children’s Health Insurance Plan (CHIP) and the Federal Employee Health Benefits (FEHB) Plan.

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