News: UnitedHealthcare adopts Sepsis-3 criteria for claims validation

UnitedHealthcare announced recently that, starting January 1, 2019, they will use sepsis-3 criteria for validating sepsis claims. This move could spell more denials for facilities in the long run, according to Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist with HCPro in Middleton, Massachusetts.

“UnitedHealthcare has a recent history of facing challenges with their insured, so it doesn’t surprise me that they are transitioning to a more conservative criteria for sepsis,” he says.

UnitedHealthcare will use the sepsis-3 criteria for all benefit plans including commercial, Medicare Advantage, and Medicaid plans. “UnitedHealthcare believes adherence to these management guidelines will result in improved quality of care and outcomes,” the announcement says.

Though the Surviving Sepsis Campaign embraced the sepsis-3 criteria last year, CMS continues to use sepsis-2 for its SEP-1 bundle under the Inpatient Quality Reporting program. Additionally, many clinicians have expressed concern that the sepsis-3 criteria may lead to a slower physician response time for potentially septic (particularly pediatric sepsis patients), and therefore, they may not get the care they need at the onset of the condition.

When ACDIS polled the membership earlier this year regarding which sepsis criteria their facilities used, only 16% said they used sepsis-3 at the time, whereas 60% used sepsis-2, and 18% used a facility-specific set of criteria.

Editor’s note: To read the full announcement from UnitedHealthcare, click here. To read the ACDIS white paper about the various sepsis definitions, click here.