BREAKING: UnitedHealthcare Sepsis-3 Criteria Not Being Used for Auditing Claims from New York Hospitals

Plan was “strongly opposed” by NY healthcare groups.

The Healthcare Association of New York (HANY) told providers Tuesday that the Empire State that it will not use the UnitedHealthcare (UHC) Sepsis-3 criteria when reviewing claims to validate sepsis for payment. New York state law defines sepsis with systemic inflammatory response syndrome (SIRS) criteria, otherwise known as Sepsis-2.

Tuesday’s announcement by HANY follows a news release from the Greater New York Healthcare Association (GNYHA) that said the group “strongly opposed UHC’s misguided proposed policy, which would have negatively impacted hospital quality improvement efforts and significantly reduced hospital reimbursement for sepsis cases.”

GNYHA confirmed that UHC had written to both the New York State Department of Health (DOH) and the New York State Department of Financial Services (DFS), stating that it would not implement Sepsis-3 criteria in the state of New York.

In defending its use of Sepsis-3 in general, UHC, in its letter to New York health officials, cited the endorsement of the new definition by 31 medical societies and providers, noting that it “provides the most clinically relevant definition of sepsis, a topic of considerable debate.”

As first reported last October by RACmonitor, UHC announced in a monthly bulletin that as of Jan. 1, 2019, the giant insurer would be using Sepsis-3 to determine if a diagnosis of sepsis is clinically validated. Ronald Hirsch, MD, in reporting the story for RACmonitor, said that UHC would use the “Sequential (sepsis-related) Organ Failure Assessment (SOFA) score to determine if sepsis is present.” Hirsch quoted UHC as saying that patients with septic shock “can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL).”

In reacting to the announcement this week, Hirsch told RACmonitor that he personally supports the Sepsis-3 definition of sepsis.

“Patients with sepsis are very sick, and have a dysregulated response to their infection,” Hirsch said in email. “SIRS criteria do not adequately differentiate that specific patient population. I also think that the goal of medical care is to prevent patients from becoming critically ill.”

Hirsch went to say that if providers use SIRS criteria to screen for patients who are at risk for developing sepsis and treat them aggressively, preventing sepsis from developing, then providers cannot rightfully say the patient had sepsis.

“I can understand the unwillingness of payors to pay for an admission for sepsis when the patient was prevented from developing sepsis by good medical care,” Hirsch said. “Perhaps it is a flaw in our system where providers get more money if a patient gets sicker and there is no financial reward from preventing a life-threatening illness.”

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