Which definition of the deadly condition will be applied in the Empire State has been a hot topic of late.
EDITOR’S NOTE: The following is partial transcript of remarks made by Dennis Jones during a recent RACmonitor-produced Monitor Mondays broadcast.
First, let me remind everyone that I am in the finance department of my hospital (Montefiore Nyack): a boring accountant type whose days are consumed with reading explanation of benefits documents and realizing that most CARC (claim adjustment reason codes) codes mean pretty much the same thing.
I am not one to explain the finer points of sepsis criteria.
However, let me nonetheless review the recent developments in New York State regarding UnitedHealthcare’s application of the Sepsis-3 criteria to review claims.
To begin with, UnitedHealth Care (UHC) published an October 2018 network bulletin on Sepsis-3. In the bulletin, UHC proclaimed that it would use the criteria in its claim reviews.
New York State has a unique circumstance regarding the application of Sepsis-3 criteria that goes back to a tragic incident in 2012.
That year, a young boy named Rory Staunton, 12 years old, cut his arm in gym class while diving for possession of a basketball.
The gym teacher dressed the wound, but before the next day, Rory was sick with a fever and leg pain and vomiting. Rory saw a pediatrician who referred him to the emergency room of a New York City hospital.
The hospital saw the symptoms and treated Rory for a flu bug that was going around. The boy was discharged prior to the result of lab tests that would have shown the presence of a blood infection.
Sadly, Rory later died from sepsis, which could have been successfully treated if it had been recognized early.
New York State subsequently passed Rory’s Regulation, which requires hospitals to take the following action:
At the time, Sepsis-2 criteria were widely accepted for the purpose of identifying and treating sepsis.
When UHC published its intent to utilize Sepsis-3 criteria, it was in conflict with the New York State Department of Health (NYS DOH) regulations.
On Dec. 18, 2018, the Greater New York Healthcare Association (GNYHA) and the Healthcare Association of New York (HANY) sent a letter to the NYS DOH pointing out the differences between the Systemic Inflammatory Response Syndrome (SIRS)-based Sepsis-2 definition and the Sequential Organ Failure Assessment (SOFA)-based Sepsis-3 definition.
In the letter, the hospital associations stated:
Sepsis-2 bases the recognition of sepsis on SIRS criteria and therefore allows clinicians to consider a sepsis diagnosis much earlier in the advancement of the disease. The criteria prompt clinicians to initiate rigorous monitoring and treatment protocols to avoid escalation of sepsis into organ dysfunction, further morbidity, and mortality.
The letter went on to state:
We believe insurers that are adopting the Sepsis-3 definition are doing so not for the purpose of improving the quality of care, but simply as a mechanism to down-code claims and reduce payments to providers.
As a result, the NYS DOH pointed out the regulatory issue in a letter to UHC, and on Jan. 3, 2019, UHC issued a statement defending its use of Sepsis-3 criteria, but conceding that “nonetheless, UnitedHealthcare will not apply Sepsis-3 to NY providers until such time as NY adopts the updated criteria.”
This may sound like a temporary reprieve, but since the Sepsis-2 criteria identify possible cases of sepsis earlier, at the cost of the possibility of some false-positive sepsis cases, New York State may not be in a hurry to change its current sepsis definition and Rory’s Regulation.
HANYS has stated that it will continue to push back against the use of Sepsis-3 criteria by other payers.
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