In a May 3 letter to CHA, UnitedHealthcare (UHC) announced it will temporarily suspend implementation of its new sepsis review policy in California until Nov. 1. The delay — a result of CHA’s advocacy on the issue — is intended to allow additional time to work through administrative and other issues that are unique to the California market, in particular due to California hospitals’ prevalent use of full-risk, capitated, delegated network arrangements.
CHA and members met with UHC on March 7 and April 30 to discuss its revised policy pertaining to sepsis treatment and payment. UHC had previously indicated that, effective Jan. 1, 2019, it would use only the Sepsis-3 definition — which has not yet been universally adopted — for post-payment reviews of payments made to providers that currently contract with UHC using the Medicare Severity Diagnosis Related Groups (MS-DRG) fee schedule. Further, UHC indicated that if, upon review of the medical record, it determines that the patient has not met the Sepsis-3 definition, it will downgrade the MS-DRG to reflect that “sepsis was not present and sepsis treatment services should not have been included as part of the member’s claim.”
In an April 18 letter to UHC, CHA shared our vigorous opposition to this change in policy, which is seriously misguided, fails to recognize the importance and value of early intervention to avoid poor outcomes, second guesses the medical decisions of infectious disease specialists, misinterprets the Sepsis-3 definition, is inconsistent with Centers for Medicare & Medicaid Services requirements, and may violate California law. In the letter and in in-person meetings, CHA urged UHC to rescind the policy immediately.
A number of outstanding concerns about UHC’s policy remain; CHA looks forward to working with members and UHC in the coming months to resolve them.