Starting January 1, United Healthcare will use sepsis-3 criteria for the medical necessity of claims. Experts believe this could lead to higher denials in the near future. This change is for all of United Healthcare’s plans.
Sepsis-3 defines sepsis as “life-threatening organ dysfunction caused by dysregulated host response to infection [suspected or confirmed].” Two standards can be used prove organ dysfunction. Sequential Organ Failure Assessment (SOFA) score of two points or more, or for patients that are suspected of having an infection quickSOFA (qSOFA) can identify patients with two of the following three clinical criteria: systolic blood pressure of 100 mmHG or less; altered mentation; or respiratory rate of 22 breaths a minute or more.
Educating physicians and coders about this before the change will be important. Preparing for, and preventing, these medical necessity denials is necessary to maintain revenue. A poll earlier this year by the Association of Clinical Documentation Improvement Specialists found that 16% of facilities are currently using sepsis-3.
Medicare Part C
The Supreme Court has recently decided to take up a case arguing whether the Department of Health and Human Services had to engage in notice and comment rulemaking when it changed the Disproportionate Share Hospital adjustments to include Medicare Part C days in the Medicare fraction. The government is currently appealing the Court of Appeals’ decision stating that it was not allowed to make this change in a mere interpretive rule that does not require comments and notice.
If the current ruling stands, DSH payments over several years, worth possibly billions of dollars, would be impacted. Even further, other interpretive rules the HHS has promulgated could be subject to legal review, potentially further changing how reimbursement from the government is calculated. The amount of money at play here could ripple for years to come and it is important to pay attention to this case.
Medicare Beneficiary Identifiers
Finally, the OIG did not add many new items to its work plan this month, but one that will possibly affect your bottom line is the review of the roll out of the new Medicare ID cards. In particular, the OIG is interested in payments providers have received for cards that were mailed to beneficiaries but returned to the Centers for Medicare & Medicaid Services. These possibly fraudulent payments would obviously be taken back by the government, so it is important to ensure that you have safeguards in place to determine the correct patient identify as much as possible. Asking for multiple forms of identification, determining if the patient’s Medicare Beneficiary Identifier is the same as the last time they entered the facility, and possibly, asking patients presenting this card for the first time for their Social Security Number which would be their previous Medicare ID number.
The OIG also states that it will be reviewing payments for “high risk” cards as well. It does not state how it has determined a patient is a high risk, or how much MBI fraud it is expecting, but it is important to ensure providers do their part to determine payment is being requested for the right patients, for the right services.
As a final note, repeat readers here may be interested to learn that a recent study published in JAMA Network Open found that from 2011 to 2015, one in six ED patients would have had their claims denied by Anthem if their ED policy was in place nationwide during that period.
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