THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net
Date: Fri, 31 Aug 2007 17:45:49 -0700
08 02 04 61 07083101
Clinical Research Department
University of California San Francisco Medical Center
Carol Franc Buck Breast Care Center
1600 Divisadero, Second Floor
San Francisco, CA 94115
..
Millie was elated by continued decline of the blood test for CA 15-3 to 28, as
reported in your letter this morning. Improved cancer marker diagnostics align
with CT test results, and continues improvement under Doctor Rugo's care at
UCSF,
ordered by Kaiser on 070105.
..
Favorable cancer marker is a great send off for her vacation next week.
..
By copy to Arlette, I am notifying [primary care physician]
at Kaiser to update Millie's
medical chart to prepare for meeting with Millie scheduled next month, as part
of Kaiser's continuing care, control, and responsibility for this case.
..
As we discussed yesterday, I met with Bob Schwartz at UCSF accounting offices
on Harrison Street to review billing issues that have come up the past few
weeks, when Millie suddenly received a rash of about 30 documents from UCSF and
an equal number from Kaiser backdated for work beginning on or about January
30, 2007, when Millie first met with Doctor Rugo and her team at UCSF.
..
Bob seemed unaware that Millie had been treated for 7 or 8 months without
getting invoices.
..
Bob explained yesterday that UCSF billings for services to date in the
approximate amount of
$4,300
will be increasing because of additional work UCSF
has performed since the initial statement received a few weeks ago. Just
guessing this appears to roll up to about
$10K for the year.
..
Bob was very helpful explaining
UCSF billings
to the patient are based solely
on mathematical manipulations presented by Kaiser acting as an agent for
Medicare. He pointed out that to support cost containment UCSF and Kaiser
through its Medicare affiliate have entered into contractual agreement on
amounts to compensate UCSF for reasonable and necessary costs of services.
..
UCSF then bills Kaiser as services are performed and coded by the doctor to
correlate with approved cost accounts. Kaiser makes payments in accordance
with the contract. Bob further explained that Kaiser tells UCSF the amount it
has over-billed based on Kaiser's understanding of the contract; but that
experts (he and colleagues) in the UCSF accounting department routinely call
their counterparts at Kaiser and
negotiate on application of Medicare
regulations,
which results in Kaiser agreeing to pay UCSF more money.
..
As shown in the record on 070823, UCSF and Kaiser go through
many iterations of
negotiation
for each transaction before finally settling on payment to UCSF.
..
This makes a lot of sense, because contracts can be reasonably interpreted in
many ways to equitably execute complex medical transactions.
..
This aligns with Millie's experience when she was
referred by her doctor on
June 28, 2002 to get treatment at Mt Diablo
hospital, which was not available
at Kaiser. As you can see, there was no disclosure of extra expenses; rather,
in the absence of disclosure notifying of additional expense which the patient
could decide proactively to accept or request a showing of justification,
alternatives, etc., Millie reasonably relied on tacit understanding that what
the doctor ordered was part of insurance coverage, the same as if performed by
Kaiser...
..
There was no discussion of Millie getting invoices for "miscellaneous
expenses," and in fact she never saw an invoice for referral work at Mt Diablo.
..
Similarly, in this case, Millie was told by her doctor on January 5, 2007 that
he made a
referral for treatment at UCSF
that was not available at Kaiser for
her "triple negative status"...
..
As with the prior experience, Millie relied on her doctor that treatment at
UCSF would be paid under her insurance the same as if performed at Kaiser.
Additionally, the doctor notified Millie in a letter on December 30, 2006
transmitting
correspondence between Kaiser and UCSF on referral arrangements
which expressly indicate Millie would have no additional costs, including
standard of care.
..
Subsequently, Millie was
notified by UCSF to begin treatment
in San Francisco
on January 19, 2007 because her condition was worsening as a result of Kaiser
ending prior treatment on December 1, 2006, which had become ineffective.
..
As shown in the record, Doctor Rugo, her assistant, Jackie, and everyone at
Kaiser, including
the primary care physician, worked very hard
over the next several weeks to resolve referral authorization issues, beginning
with [Kaiser's]
letter to Millie on January 19th, which says in part...
..
"[Kaiser] Authorization was submitted [to UCSF]..,
but new Medicare regulations
around this are confusing. Dr Rugo and I are working on it from
both ends."..
As a result, Millie was sent home on January 19th without treatment, so that
Kaiser and UCSF could resolve payment issues.
..
Millie was called a few weeks later and told the
issue was resolved, and then
met with Doctor Rugo and her team at UCSF on January 30th. At that time, she
was not asked for payment.
..
During the meeting on January 30th,
the doctor indicated that authorization and
payment issues had been resolved.
..
In light of this history, Millie was upset to start getting invoices a few
weeks ago for services beginning in January.
..
Discussion with Bob yesterday, seemed to indicate that UCSF is counting on
Kaiser's Medicare reps to designate amounts they should bill the patient.
There seems to be no correlation between any amount in UCSF billings to any
specific service performed for the patient.
..
Bob cited two general classes of payment he believes Kaiser is designating for
collection by UCSF from Millie. There is no documentation showing either
entitlement nor alignment with amounts in UCSF accounts. Bob related having to
talked to Barbara in Kaiser's Outside Referral office, and he drew from that
telephone discussion that someone in Kaiser's Medicare unit wants Millie to pay
for something being called "co-insurance" for each time she visits with Doctor
Rugo. He said these can be recognized by 8 separate charges of $101.00 on a
spreadsheet he prepared that is undated, but shows activity through August 2,
2007.
..
He explained that the column showing "Patient Responsibility" should be paid by
Millie. While the amount of $101 is the same for all 8 charges, the amount of
patient responsibility varies from $22.26 to $27.88. Naturally, we don't want
to bog down high priced professionals over a few dollars, but the question
arises about the basis for these charges, and the variance?
..
Bob explained UCSF standard practice to submit unpaid amounts to a collection
agency, or alternatively, the patient can claim indigent status, and UCSF seeks
recovery from various charity sources.
..
What was unclear in the meeting, was why, if
UCSF can negotiate over and over
with counterparts at Kaiser
to reach equitable adjustment of admittedly
confusing regulations in order to increase payment to UCSF, who is speaking for
the patient? If there is no charge for "office visits" to patients in clinical
trials, what is the basis of charging "co-insurance" for office visits. Where
is the requirement for "co-insurance" specified?
..
During the meeting, agreement was reached to give UCSF
payment for these office
visit charges.
At that time, we did not take time to check the record on why
Millie had not been making these payments. As noted, subsequent review shows
no support for these charges.
..
Bob asked that the account number on his spreadsheet be listed on the check,
and indicated payment can be submitted to the UCSF Administrative Office on the
ground floor at 1600 Divisadero, when Millie goes in for treatment next
Thursday, September 6th. In turn, Millie requests that UCSF submit controlling
authority on this issue. Are patients in clinical trials required to pay for
office visits, if so, why wasn't this disclosed on January 19th at the first
meeting, or on January 30th at the 2nd meeting, or on any of the other
meetings? Why was notice and explanation of charges withheld for 8 months
until August 30th?
..
Bob's report that Kaiser designates as "Patient Responsibility" the cost of
blood tests does not withstand scrutiny. He examined account #12593370 for
services on March 1, 2007. UCSF submitted payment request to Kaiser for
$4,549.49. Kaiser eventually paid UCSF $1,776.54 after several negotiations.
Bob seemed to explain further that the column marked "Contractual Adjustment"
reflects the amount the Kaiser Medicare rep feels was overbilled in relation to
pre-established billing rates in the contract with UCSF. He explained that
Kaiser then calculates an amount which UCSF can collect from the patient in a
column called "Patient Responsibility." Bob emphasized there is no attempt to
correlate this amount to any Medicare regulation nor to any provision in the
patient's agreement with Kaiser, rather this is a simple arithmetic
calculation. As a result, he said the doctor cannot notify the patient that
charges are being accumulated, because the only way UCSF can determine what to
bill the patient is after they complete negotiations with Kaiser.
..
We need a coordination plan to identify charges so the patient can exercise
control of expenses in the same way that UCSF and Kaiser have established a
cost-basis for performing Medicare work.
..
Bob illustrated this fact by turning to UCSF's list of detailed charges and
Kaiser's calculations on account 12593370 for services on March 1, 2007. There
is correlation between the amount UCSF billed in the invoice of $4,549.49 and
the amount on Bob's spreadsheet summary, but there is nothing showing support
for Patient Charges of $1,240.96. Bob initially pointed to page 2 to support
his understanding from discussions with Barbara in Kaiser's Outside Referral
Department that Kaiser wants the patient to pay for blood tests. He noted
there is an amount of $202.65 for "denied co-insurance," discussed above, and
there is another amount of $1028.31 for "Account balance transfer." He
initially felt this was for blood tests, but he then decided that the amount
for "LAB" of "$2,000.00" conflicts with this understanding.
..
Talking to Bob yesterday, we reviewed a meeting at Kaiser the day before on
Wednesday, August 29th. Millie and I met with another Barbara in Kaiser's
Customer Services office at the Walnut Creek facility where Millie sees her
primary care physician. Barbara investigated why Millie would be charged for
treatment on a clinical trial when Medicare regulations pay for clinical
trials.
.. Barbara submitted a Kaiser document with the title...
Section 2: What's Covered..
She pointed to a section at the bottom that says...
Clinical Laboratory Services Including blood tests, urinalysis, some screening
tests, and more.
..
Clinical trials to help doctors and researchers find better ways to prevent,
diagnose, or treat diseases. Routine costs are covered... ..
Barbara then pointed to a footnote at the bottom of the page that says...
Note: coinsurance and/or deductibles may apply. ..
Barbara handed Millie another printed paper with the title:
Medicare Clinical Trials.
She explained having printed this from a Kaiser website on the Internet.
Barbara pointed to a section that says...
Medicare will pay for many, but not all, services associated with qualifying
Clinical Trials. You should ask the Clinical Trial provider if the Clinical
Trial qualifies for Medicare payments, and what Medicare coinsurance and other
out-of-pocket expenses you will have to pay...
Since it appears from Barbara's research that "Clinical Laboratory Services,
including blood tests, urinalysis, some screening tests, and more" are covered
by Medicare, and since there is no evident correlation between UCSF billings
for services and amounts being charged the patient, there is no basis for the
patient to make payment beyond premiums paid to Kaiser and to Medicare.
..
We should try to meet with Kaiser's Medicare people to get justification for
allocation of charges. To facilitate discussion of blood testing at UCSF,
beyond the clear language in Kaiser's documentation received on August 28th,
discussion between Doctor Rugo and Doctor Johnson on December 30th is
instructive when Kaiser gave assurances that Kaiser would pay for "standard of
care."
..
Laboratory tests are materially different from image testing, e.g., xrays, CT,
PET, etc. Patient history in this case shows that image testing which is
required by the clinical trial protocol is effective performed by Kaiser,
because it requires reviewing prior test results for trend analysis to alert
the doctor of correlations, implications and nuance that are not evident from a
mere glance at figures. Lead time required for this work is several days up to
a week.
..
Blood tests are much different.
Analysis essentially occurs on the spot by the
doctor and the nurse, and often requires additional spot testing to verify the
patient can get treatment, or can be released to go home, etc. Logistics of
transportation present an initial requirement for local control of blood
testing. Another problem is communication. There was an attempt to perform
blood testing at Kaiser and have results submitted to UCSF. As shown in the
record on January 30th,
this was not effective.
..
Millie had 3 or 4 extra blood tests ordered by Kaiser which were not needed,
and which are avoided by deferring the test until it is actually needed. To
save time and money for Kaiser and UCSF, this
work was then performed by UCSF.
..
Millie's patient history listed most recently during the meeting at Kaiser on
May 25th, showing some
45 issues
presents a fragile condition subject to momentary failure which requires
blood tests at the discretion of the medical team. Doctor Rugo and Doctor
Johnson should be commended for outstanding care that demonstrates the model of
effective collaboration to save lives, time and money, illustrated
by
emergency work for Millie at UCSF on June 7th....
..
Thanks again to Bob for hard work preparing a spreadsheet that organizes the
raft of complex invoices, and for taking time yesterday to explain UCSF billing
practices. As [Millie's primary care physician at Kaiser]
noted on January 19th, more work is needed to
develop procedures to implement Medicare regulations. Arlette,
Oncology staff assistant at Kaiser
indicated on Wednesday that Millie is their first patient
being treated under new procedures, so all of us have to work together, as
trail blazers toward equitable and cost efficient implementation.
..
As well, getting a stage IV cancer patient who has relapsed 4 times to the
point of NED on CT testing, and now today registering the lowest cancer marker
in 7 years of treatment shows progress beyond belief implementing the tools of
medicine. Let's work toward the same result coordinating accounting and
billing between venerable organizations.
..
Jackie, as noted, I am sending a copy to Arlette for Doctor Johnson. Please
submit a copy to Doctor Rugo so she has a chance to review the record in
advance of getting a call from Bob to help work through these matters.