Once, an insurance company actually denied the diagnosis of “acute respiratory failure” in a case of a teenage boy who suffered cardiac arrest at home and needed a ventilator in the hospital. When the treatment team finally got around to measuring the oxygen levels, after he was on a ventilator, his oxygen levels were great. So, the insurance company said there was “no evidence of respiratory failure in the medical record.” This was ridiculous, and the most egregious example of this type of denial. But, it happens, and it happens a lot.

One particular DRG denial with which commercial payers are having a field day is the sepsis denial. The definition of sepsis (previously known as septicemia) has gone through many iterations throughout the years. In the past, sepsis was defined as “a known or suspected infection along with two or more signs of the systemic inflammatory response syndrome, better known as SIRS.” This definition is still used by the Centers for Medicare and Medicaid Services (CMS) today.

In 2016, an International Consensus Group came together and re-defined sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” How do you define “life-threatening organ dysfunction”? They said that this can be operationalized by an increase in the SOFA score by 2 points of more, SOFA being “Sequential [Sepsis-related] Organ Failure Assessment.”

SOFA assigns a specific point value for dysfunction is six organ systems: mental status, oxygenation, blood pressure, bilirubin, platelet level, and renal function. The worse the organ failure, the higher the SOFA score. A normal, healthy human has a SOFA score of 0.

As a critical care physician, I understand why this change in the definition was made. Using the “old” definition of sepsis, which we call Sepsis-2, a patient with a urinary tract infection who has a fever and high heart rate has a diagnosis of “sepsis.” Yet, in clinical practice, this is really not sepsis. Sepsis is organ failure as a result of infection. A fever and high heart rate is not organ failure, it is a reaction of the body to inflammation.

If someone has a urinary tract infection and has renal failure and shock as a result, however, that is truly sepsis. The new definition of sepsis, called Sepsis-3, better encapsulates those patients who truly have sepsis. And word to the wise: if you were to call me up and say, “Hey Dr. Hassaballa, I can’t come to work today because I’m septic with a cold, a fever, and my heart rate is 105,” I would say, “Umm…that’s not sepsis. You better show up to work.”

This change in definition is not without controversy, and it does not help that CMS has one definition of sepsis (and holds hospitals to that definition) while the literature suggests another definition. Commercial payers have dived into this controversy head-on, and I have lost count of the number of DRG denials that come across my desk related to the definition of sepsis.

For example: a patient presents to the hospital with a pneumonia, and he has an elevated white blood cell count, a fever of 103, and a heart rate of 115 beats per minute. His blood pressure is normal, his kidney function is normal, he is awake and alert, he has no other organ failure. The doctor treating this patient, using Sepsis-2, diagnoses the patient with sepsis. The claim goes to the commercial insurance company, and they look through the chart and deny payment saying, “There is no evidence of sepsis in this record according to Sepsis-3.” Technically, they would be absolutely correct.

Now, they do these types of denials because, if there is no sepsis, the severity of illness related to the hospital stay decreases. And, with a lower severity of illness, the payment to the hospital will also become lower. In fact, many times, the insurance company will say in a letter, “We issued an overpayment on this claim. We looked at the record, and there was no evidence for sepsis. Thus, you owe us $10,000.”

That’s when I get the appeal, to argue against the allegation that there was no sepsis. Yet, if there is no organ failure, if there is no hypoxia, or shock, or renal failure, or high bilirubin, or altered mental status, or low platelet count, then there really is no sepsis according to Sepsis-3. And, therefore, my appeal will be inherently weak, because Sepsis-2 is not the most recent, evidence-based definition for sepsis. It just is not.

So how to avoid these denials? In short: check the face sheet.

The face sheet is the part of the chart that has the demographic and insurance information for the patient. If the patient has commercial insurance or has a Medicare Advantage plan, I will bet you dollars to donuts that they will be using Sepsis-3 as their definition for sepsis (and they are not wrong to do so). If the patient has traditional Medicare, however, the definition for is sepsis is Sepsis-2, which is SIRS plus infection.

Yes, it is confusing. Yes, it is quirky. Yes, it is annoying. It is the way of the world in 2022, and we clinicians have to become more sophisticated in our understanding of how our healthcare world operates in the United States. Complaining about it and saying, “Well this is ridiculous” does not change the reality. If we just spend the extra ten seconds and look at the face sheet, we can save ourselves a whole lot of pain and suffering later by avoiding a sepsis DRG denial. It is truly time well-spent.

The post From The Appeals Desk: Know Your Sepsis appeared first on Medika Life.

MA plans entice seniors with “zero premium” plans, lower maximum out-of-pocket costs, dental, vision, and hearing coverage. These marketing efforts have been very successful. In a Kaiser report for 2020, MA enrollment was at 39% of Medicare enrollees for a total of 24.1 million Americans. Four large insurers; United Healthcare, Humana, Blue Cross/Anthem, and CVS Health provide coverage for 70% of MA members

What MA plans and CMS don’t fully explain to seniors is the significant back-end costs that can escalate when they get sick or develop chronic diseases. If seniors do not stay in the network or have services that are not approved by the health plan, out-of-pocket expenses can reach $8800-$10,000. These higher costs during an illness put a significant financial burden on seniors with fixed incomes. In many cases, seniors have no option but to declare bankruptcy.

Gaming the System

MA plans can receive increased payments from CMS if they enroll sicker patients. The hierarchical condition category (HCC) which started in 2004, relies on ICD-10 coding to assign risk scores to patients. CMS uses HCC coding to assign patients a risk adjustment factor (RAF) which impacts health plan revenue.  In a public integrity report, risk score errors triggered nearly $70 billion in “improper” payments to MA plans from 2008 through 2013. In addition, between 2007 and 2011, the report found that risk scores of MA patients rose sharply in plans in at least 1,000 counties nationwide, increasing taxpayer costs by more than $36 billion over estimated costs of caring for patients in traditional Medicare in those same counties.

Despite the high RAF’s in some of these plans, MA attracts healthier enrollees than traditional Medicare. In 2016, members who switched to MA from traditional Medicare spent on average $1253 less per member compared to those that remained in traditional Medicare. Even among traditional Medicare beneficiaries with specific health conditions, those who shifted to MA in 2016 had lower average spending in 2015, including patients with diabetes ($1,072), asthma ($1,410), and breast or prostate cancer ($1,517).

Sicker members are opting out of MA into traditional Medicare because of lack of access to providers and the higher cost of care. Researchers at Brown University found that 17% of MA  patients who entered nursing homes for long term care chose to switch to traditional Medicare the following year. The experience was similar for members who required short term nursing care or home health care. MA plan design with restrictive networks and high out-of-pocket expenses when members get sick have helped MA plans drive higher cost members to traditional Medicare.

Medicare Advantage Costs Taxpayers More than Traditional Medicare

MA Plans were expected to be more efficient than traditional Medicare and reduce the cost for taxpayers. But this has never been the case since MA started in 2003. Funding to MA plans begins at 98% of traditional Medicare funding (since MA should be more efficient), but when you add in star bonuses (quality bonus), funding rises by 3%, and adjusting for acuity coding (RAF), funding increases another 2-5.5%. With all the adjustments MA plans are costing taxpayers 2-5% more than the traditional Medicare program. In contrast, If a traditional Medicare member receives care from an Accountable Care Organization (ACO), the cost to taxpayers goes down by 1-2%.

Excessive Profits

All of these factors have contributed to excessive profits for these large insurance companies. United Healthcare, the largest insurer for MA, posted a profit of $3.5 billion for the fourth quarter of 2019, with an annual profit of $13.8 billion. Humana, the second largest insurer for MA, reported $64.9 billion in revenue for 2019, and earned $2.7 billion in profit for the year, up from $1.7 billion the year prior.

These excessive profits are providing CEOs with exorbitant annual total compensation packages. In 2019, the CEO of CVS Health received a staggering $36.5 million in total compensation, followed by the CEO of United Healthcare whose total compensation was $18.8 million.

Medical Debt and Bankruptcy

While MA is great for large insurers and their CEOs, seniors are seeing more financial risk shifted to them with larger deductibles, co-pays, and co-insurance, resulting in higher costs, and significant debt. The percentage of households headed by an adult aged 65 or older with any debt increased from 41.5% in 1992 to 60% in 2016. The median total debt for senior households was $31,300 in 2016; more than 2.5 times what it was in 2001.

The increased debt burden has forced more seniors into bankruptcy with over 60% citing high medical costs as the reason. Data from the Consumer Bankruptcy Project demonstrates that since 1991, there has been a five-fold increase in seniors filing bankruptcy. In 2020, 1 in 7 people who filed for bankruptcy was age 65 or older.

Before filing bankruptcy, many seniors forego healthcare to try and save money to help pay for the debt. Over half (52 percent) indicated that the single most important item they had to forego the year prior to filing bankruptcy was related to medical care and included surgeries, doctor visits, prescriptions, and dental care.

The following is a quote that summarizes what seniors are experiencing. “My bankruptcy started with back surgery I had in 2011. I had several medical tests that my insurance did not cover. This caused me to fall behind in my medical payments. The next thing I knew, the bills began piling up. I got to the point I owed more than I was making on Social Security. To get out from under these medical bills I had to file bankruptcy.”

Future of Medicare

In 2020, the 65 and older age group made up 21% of the total population and by 2030, 24% of Americans will be 65 and older. Nearly a quarter of the country will be looking for affordable healthcare in retirement. MA is clearly not the solution:

• MA costs taxpayers more money than traditional Medicare.
• Large insurers can’t be trusted, they game the system to maximize profits.
  • Profits and administrative costs create an unsustainable financial model to provide affordable healthcare for seniors.
• MA plans back-end costs put seniors at financial risk when they get sick or develop chronic conditions.
  • The number of seniors that file bankruptcy is on the rise
• Seniors need a public safety net option
  • Traditional Medicare can be the public option by expanding ACO models of care and investing in more innovation.

The post Privatizing Medicare: Greed is Creating a Financial Crisis for Seniors appeared first on Medika Life.