Definition of Sepsis for Purposes of Health Insurance Coverage

The Department of Financial Services (DFS) and the Department of Health (DOH) have received complaints from hospitals that some health insurers have recently changed their definition of “sepsis” from Sepsis-2 to a new definition that was introduced in 2016 by “The Third International Consensus Definitions for Sepsis and Septic Shock,” referred to as Sepsis-3. The Sepsis-3 definition is narrower than the Sepsis-2 definition. In response to the complaints the two Departments have received, the DOH has issued guidance to its regulated entities explaining why using the Sepsis-3 definition in New York is problematic and directing managed care organizations to use the Sepsis-2 definition to ensure correct reporting and reimbursement of the screening and treatment protocols required of hospitals under NYS DOH regulations. Please follow the attached link to the guidance issued by the DOH for a full explanation of the directive to use the Sepsis-2 definition. DFS expects insurers to act consistently with the DOH’s guidance.