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The UHC sepsis definition raises new audit concerns.

Each month, UnitedHealthcare (UHC) keeps providers appraised about its policy changes with an online bulletin. These bulletins contain important information about pre-authorization requirements, changes to preferred providers, new fax numbers, and much more.

In most cases, I read through it and find little of interest to the broad RACmonitor audience, but the October edition was an exception. Contained within the 61 pages are several important things that physician advisors and utilization review staff should read and save, perhaps even sacrificing a tree to print them out and pin them on an office bulletin board.

First, UHC announced (click link here and go to page 7) that as of Jan. 1, 2019, it will be using the SEP-3 definition to determine if a diagnosis of sepsis is clinically validated. UHC also notes that the “Sequential (sepsis-related) Organ Failure Assessment (SOFA) score be used to determine if sepsis is present.” UHC also notes 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 the absence of hypovolemia.”

While adopting this definition makes clinical sense, this policy raises questions for providers. If the SOFA score is not documented, will the UHC reviewers go into the medical record, seek out the lab values, the vital signs, the oxygen rate, calculate a Glasgow coma score (GCS), and then calculate the SOFA score? Or will they remove the sepsis diagnosis from the claim simply because a doctor did not document “SOFA = 4,” or actually calculate the GCS?

The provider bulletin also addresses status determinations for patients with coverage by one of the many UHC Medicare Advantage plans. That is an area fraught with controversy. As I reported on Monitor Mondays on Oct. 1, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently released a report titled “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials.” In this report, the OIG reviewed denials by Medicare Advantage plans based on their concern that the plans were inappropriately denying “access to services and payment in an attempt to increase their profits.”

The OIG noted that in 2015, of the 140 contracts that the Centers for Medicare & Medicaid Services (CMS) audited, it cited 56 percent for inappropriately denying requests and 45 percent for sending insufficient denial letters. The OIG goes on to describe previous enforcement actions taken by CMS against these plans, noting that nine MA plans were fined a total of $1.9 million (with one plan actually fined a mere $3,300). Another plan inappropriately denied more than 2,000 claims; it was fined only $150 per denial.

The OIG notes that of the approximately 300,000 denial appeals that were filed by patients and providers each year from 2016 to 2018, over 75 percent were successful. It also reported that there were 76 MA contracts that had over 98 percent of their denials overturned. The OIG also notes that only a small number of denials are actually appealed. Together, these facts tell the OIG that the appeal process is too confusing, and often overwhelming for most patients, especially those with critical medical issues – and that if more patients and providers appealed, their chances of success would be high.

Anecdotally, one of the most common denials faced by hospitals from commercial and Medicare Advantage plans is that of an inpatient admission, with it often being stated that the care could have been provided as outpatient with observation services, even when the patient spent more than 48 hours in the hospital. As with the findings by the OIG, when appealed, many of these denials are overturned, suggesting that the denial was not appropriate.

Under the two-midnight rule, for traditional Medicare patients, no patient in a medically necessary hospital stay should pass the second midnight without an admission order being written. And it appears that UHC policy H-005, titled Observation Care (Outpatient Hospital), which was updated Aug. 21, 2018, now supports that, stating that “in the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.” That means that by UHC’s own policy, patients should not remain as outpatient with observation services for more than 48 hours – unless, of course, there is a delay in care or the ongoing stay is due to convenience.

This also aligns with UHC’s inpatient admission policy H-006, also updated on Aug. 21, 2018, which states that “the physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. Physicians should use a 24-hour period as a benchmark, i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more and treat other patients on an outpatient basis.”

In other words, the UHC policies seem to align with the Medicare regulations, and if a patient is approaching the 48-hour mark (the second midnight mark, for traditional Medicare patients) and they continue to require hospital care – even if that care is at the same intensity of the care provided under observation, or even less intense but still requiring hospitalization – the patient should be admitted as inpatient and UHC should approve the inpatient admission.

Unlike Humana, another Medicare Advantage plan supplier, UHC also appears in policy H-006 to be recognizing the CMS inpatient-only list for surgeries, including a reference to it. As I have reported here in the past, Humana noted that the inpatient-only list does not apply to their members, and they can authorize surgeries such as total knee replacements, hip fracture repairs, and even carotid artery stenting, at surgery centers.

It is clear from the Medicare Managed Care Manual that as long as the patient receives the necessary care, CMS leaves the payment and status decisions to the providers and payers. But when the OIG finds that a majority of denials are overturned, it is time to take a closer look at payer policies. And in the case of UHC, reading the policies and knowing the details should assist providers who are facing inpatient admission denials. Unfortunately, the ambiguity of clinical validation for sepsis may be less clear-cut, and certainly worth following.

Program Note:

Register to listen to Dr. Ronald Hirsch every Monday on Monitor Mondays at 10-10:30 a.m. ET.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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