Time Crunch Applies to Sepsis Treatment

It just seems that a week does not go by when an insurance company doesn’t develop a new policy that leads to confusion in the utilization review and finance departments in hospitals.

We have talked endlessly about Aetna’s development of their Medicare Advantage (MA) severity index, enabling them to approve an inpatient admission while paying the hospital an “observation-like” rate for the hospital stay. Then Elevance developed the scheme through which they pay the hospital 10 percent less if any physician providing services to the patient is out-of-network.

And in the last few weeks, UnitedHealthcare (UHC) has started to deny inpatient admissions when the hospital does not submit clinical notes within two hours of submitting a notice of admission to them. But to add to the confusion, they blame the Centers for Medicare & Medicaid Services (CMS) for this change in policy.

In the notices they send to the hospital, they state that “due to a change in CMS guidelines, clinicals must now be received within 2 hours, rather than 24 hours.”

“Change in CMS guidelines?” CMS had not released any new guidelines. And if this is a change in CMS rules, why is no other MA plan sending out the same notification? Even Dr. Eddie Hu, the true master of CMS regulations, cannot find a single CMS policy or statement that justifies this.

If you get one of these notices, please ask UHC to cite the actual guideline to which they refer. Be sure your contracting and finance teams are aware of this change, and understand that more denials will be forthcoming, increasing costs and need for resources while reducing revenue. And rest assured that many, including me, have already informed CMS that UHC is inappropriately blaming them.

Moving on, I try not to venture into the world of clinical documentation integrity (CDI) too much, but this is too big to not discuss. Late last week, the Surviving Sepsis Campaign released new guidelines on the treatment of sepsis after once again reviewing the literature. And there are some significant changes.

First, to support what Dr. Erica Remer and I have been saying for years, patients with sepsis are sick. They are not simply febrile, with an elevated heart rate. The first sentence of this 74-page document defines sepsis as life-threatening organ dysfunction due to infection.

What do they say about Systemic Inflammatory Response Syndrome (SIRS)? They recommend it as one of four screening tools that can be used (not for diagnosis, but for screening). That means SIRS plus infection does not necessarily equal sepsis. There must be organ dysfunction.

Now, what about the use of the Sequential Organ Failure Assessment (SOFA) score, the favorite tool of payers to deny the diagnosis in clinical validation audits by claiming that a SOFA change of two or more is required? Well, the authors state that “sepsis is a clinical diagnosis and should not be ruled in or ruled out using a single biomarker or diagnostic test.” In fact, they acknowledge that SOFA is a poor screening tool and should not be used, but do not totally discount SOFA itself.

I will also note that the authors specifically recommend against using Vitamin C or Vitamin D as a treatment for sepsis. They also have several recommendations pertinent to case managers and social workers, noting recommendations that patients with sepsis should have their goals of care addressed within 72 hours and should be screened for economic and social support needs – including housing, nutritional, financial, and spiritual support – and those who survive sepsis should have an opportunity to execute an advance directive prior to discharge. Of course, the guidelines address antibiotics and fluids and all that medical stuff, but we will leave that to the doctors.

And while UHC requires records to be sent within two hours, patients with sepsis or probable sepsis should get antibiotics started within one hour.

Now, will this new guideline fix the sepsis CDI mess? Of course not, but I can occasionally be optimistic.