From the Appeals Desk: We Get No Credit For Being Good Clinicians

I was honored to be on a panel of experts for a webinar on sepsis denials by payers, especially commercial insurance companies. I had previously written about "knowing your sepsis," especially since different payers use - and hold us to - different definitions for the same disease process. It can be absolutely maddening.

It was a great conversation. During the conversation, a fellow physician remarked to me about a common clinical scenario: An elderly patient will present to the hospital emergency department looking quite sick. He has a urinary infection, acute kidney injury, altered mental status, and a low blood pressure. We evaluate said patient and aggressively intervene with IV fluids, antibiotics, and close monitoring. The patient greatly improves by the following day, and he is discharged from the hospital. It is a great patient care win.

The insurance company - weeks to months after the fact - will then send a denial notice to the hospital, refusing to pay for the care that was delivered because the "patient was not that sick" and did not warrant the inpatient level of care. And then the fight ensues, frequently enlisting Physician Advisors like me to argue the case for proper reimbursement.

There's the rub, it seems. If that same patient had gotten sicker, developed acute renal failure and shock, needed invasive mechanical ventilation, and was admitted to the intensive care unit, there would be no question (one would hope) that the hospital would receive the proper reimbursement for all the care that was delivered. It is a strange and frustrating paradox, and it highlights an important point:

We do not get credit for being good clinicians.

There is no diagnostic code for "could have become septic if we didn't intervene." There is no DRG that says, "this patient is sick, and I can't wait for her to get sicker." There is NO WAY that I would EVER wait for a patient to develop organ failure so that I can definitively diagnose her with sepsis according to the Sepsis-3 definition. And yet, if I even smell sepsis on a patient, if I have the slightest suspicion that a patient is septic, I will aggressively intervene so I can prevent that patient from developing multiorgan failure and death.

And if I don't get credit for that, then so what. Who cares. It is why I became a doctor in the first place.

At the same time, there is something we can do as clinicians to better tell the story about that sick patient upon whom we aggressively intervened. We can document our thinking process much, much better.

For example, for that patient scenario mentioned above, if we write in the medical record:

Assessment and Plan:

1. UTI

• Admit for IVF and IV antibiotics

This doesn't really capture "how sick" the patient really was. It does not capture our clinical concern, our "gut feeling" that - if we do not aggressively intervene - the patient will get worse and develop "full blown" sepsis.

Contrast that with this documentation on the same patient:

"This is an elderly man with multiple comorbid conditions that place him at very high risk for adverse outcome and acute deterioration. He presents with a urinary tract infection, acute metabolic encephalopathy, acute kidney injury, and hypotension. All of these complications are likely related to the urinary tract infection itself. He looks quite ill on examination. If we do not aggressively intervene, he is at great risk for sepsis, organ failure, and death. As a result, he will be admitted to the hospital for close monitoring, IV antibiotic therapy, IV fluid resuscitation, serial laboratory assessment to monitor renal function, and serial reassessments."

Now, if this patient gets better by the following day, the commercial insurance company may still deny the care for "lack of medical necessity" for inpatient admission. Yet, it is so much easier to defend the care of the clinician who wrote the second paragraph. This second paragraph better encapsulates how the patient appeared to the clinician and why the clinician decided to admit the patient as an inpatient in the first place.

It all comes down to documentation. It is the only thing upon which everyone - other clinicians, regulators, payers, third parties, and auditors (like myself) - relies: the clinicians' documentation in the record. If it is poor, everything becomes that much harder.

Poor documentation makes it much easier for a commercial insurance company to deny medically necessary care. Poor documentation makes it much easier for an auditor to go back and deny this diagnosis or that. Poor documentation adversely affects so much in today's healthcare world. In the era of EMRs, dictation, and technology, there is really no excuse for poor documentation.

Yes, it is true that we do not get credit for being good clinicians. We do not get more reimbursement if we do the right thing and aggressively treat a patient and prevent organ failure and death. If anything, commercial insurance payers may penalize us by refusing to pay for the care at the appropriate level deserved. It is annoying. It is infuriating. It is patently unfair.

We push back against this by properly documenting in the record what we are doing and why. And, at the end of the day, if we do right by that patient and prevent him from dying from sepsis, then that is a wonderful thing. It is why we went into healthcare in the first place.