Aligning on sepsis: The education and tech health plans need now

Sepsis is one of the most urgent, complex, and costly conditions in healthcare—and one of the most disputed. Despite advances in medical knowledge, disagreements around how sepsis is defined, diagnosed, and documented remain widespread. 

In a 2023 ACDIS survey, more than 80% of respondents ranked sepsis among their most frequently denied diagnoses, highlighting how pervasive the disconnect has become. Yet the root cause isn’t malice or misalignment of goals but rather the absence of a shared, consistently applied framework and the operational tools and technology required to put it into practice.

Today, the healthcare industry has a critical opportunity to move from disagreement to partnership. By strengthening provider education, clarifying expectations, and leveraging advanced technology, organizations can establish a unified approach to sepsis that improves clinical accuracy, reduces disputes, and ultimately strengthens patient care.

Why sepsis is so challenging—and why it matters

Sepsis sits at the intersection of clinical nuance and operational complexity. Definitions vary across organizations, and different clinicians may rely on Sepsis-2, Sepsis-3, qSOFA, or internally adapted criteria. Providers must make rapid, high-stakes decisions in real time, often in chaotic clinical environments. Later, coders must translate those decisions into documentation that supports accurate billing and coding.

For health plans, retrospective review introduces another layer of complexity. Auditors are tasked with reviewing hundreds of pages of clinical records, often long after discharge. With high volumes and variable documentation styles, even minor omissions can lead to divergent interpretations and denials. Human error—on either side—is not only possible but inevitable.

These challenges aren’t simply administrative. When documentation doesn’t clearly support a sepsis diagnosis, the result may be avoidable denials, prolonged appeals, and confusion around clinical intent. This friction strains relationships and diverts attention from patient care.

The path forward: Education, alignment, and technology

Improving sepsis accuracy and consistency requires more than selecting a definition. It also requires ensuring clinicians and coders can reliably apply that definition at the point of care and billing.

Plans should consider investing in the following: 

1. Strengthen provider education

Training is the foundation. Clinicians and coding teams need clear, accessible, and ongoing education on how the health plan defines sepsis and the required documentation criteria. This ensures alignment before cases are reviewed retrospectively.

Consistent education also reduces variability across shifts, locations, and specialties—one of the major contributors to diagnostic inconsistency.

2. Enable real-time insight

When discrepancies surface only after discharge, the burden grows. The ability to identify missing documentation or criteria earlier in the process creates opportunities for rapid clarification and prevents denials.

3. Leverage technology to scale and sustain alignment

Even the most well-trained teams need support. Modern AI tools can now:

• Detect and surface key clinical indicators across hundreds of pages of documentation
• Apply Sepsis-2, Sepsis-3, qSOFA, or hybrid criteria according to the specific  payer policy
• Flag discrepancies proactively
• Provide a transparent rationale for decisions
• Align prospective (UM) and retrospective (PI) review logic
• Create consistent audit trails
• Deliver feedback loops that strengthen provider understanding over time

Technology is not a replacement for clinical judgment, but it is an essential for consistency, accuracy, and partnership.

A new model for collaboration

Health plans are uniquely positioned to align providers around shared criteria, while providers are eager for clearer expectations and more predictable billing outcomes. When both sides have access to the same transparent logic, documentation, evidence, and feedback loops, sepsis reviews can shift from adversarial to collaborative.

The result: fewer denials, fewer appeals, stronger documentation, and more trust.

How Cohere Health supports this shift

Cohere Health enables this collaborative model through AI-driven clinical intelligence and integrated review workflows that support both UM and PI. Tools like Cohere Validate help health plans proactively identify documentation gaps, reinforce agreed-upon criteria, and streamline retrospective clinical validation with transparent, scalable logic.

For organizations looking to go even deeper, Cohere’s Sepsis Audit Agent applies the same evidence-based framework to automate case review, surface documentation signals, and ensure consistent application of Sepsis-2, Sepsis-3, qSOFA, or hybrid criteria. Together, these tools provide plans with a unified, defensible approach to one of the most contested inpatient diagnoses.

This blog only scratches the surface. To explore the data, strategies, and technology framework behind a more collaborative and accurate approach to sepsis, download the full white paper.