CONTACTS 
0204 - UCSF Medical Center                                                                                                                                                O-00000875 0305
020401 - Mr. Robert Zvi Schwartz, MPH                                                                                                                                     O-00000875 0305
020402 - Patient Financial Consultant
020404 - Patient Financial Services

SUBJECTS
UCSF Billings Payments Treatments Cancer IBC Referral Kaiser Senior

1703 -
1703 -    ..
1704 - Summary/Objective
1705 -
170501 - Follow up ref SDS 7 0000.
170502 -
170503 -
170504 -
170506 -  ..
1706 -
1707 -
1708 - Progress
1709 -
170901 - Millie said today that in the past few weeks she has suddenly received
170902 - a lot of invoices and statements from UCSF claiming entitlement to
170903 - payment for work beginning on 070116 and associated with Millie's
170904 - treatments in the clinical trial for cetuximab and carboplatin.
170906 -  ..
170907 - This seems conflicting with the letter Millie received from the
170908 - primary care physician at Kaiser on 061230 saying that Kaiser would
170909 - pay for expenses of Millie's treatment at UCSF which are not paid by
170910 - the clinical trial. ref SDS 1 3X6K
170912 -  ..
170913 - Asked Millie to assemble all of the documents received from UCSF and
170914 - from Kaiser pertaining to payment for treatment at UCSF.
170916 -  ..
170917 - Review shows about 30 documents received from Kaiser which are form
170918 - letters without a name nor contact information to request correction.
170919 - Every letter says the same thing, denying payment for treatment at
170920 - UCSF on grounds the doctor did not authorize the work.  This conflicts
170921 - with the record on 070105 showing the doctor prescribed treatment at
170922 - UCSF, ref SDS 2 PK68, after having made arrangements on 061230 for
170923 - Kaiser to pay any costs not covered by the clinical trial. ref SDS 1
170924 - 3X6K
170925 -
170926 -     [On 071128 Kaiser Appeals Committee approved payment for Millie's
170927 -     care on referral to UCSF. ref SDS 15 JZ5R
170929 -  ..
170930 - Millie has, also, received approximately 30 documents from UCSF.  Some
170931 - are identified as invoices and others are statements, however, nothing
170932 - shows the total amount claimed by UCSF, and the basis for charges.
170934 -  ..
170935 - UCSF statements show Medicare making payments for Millie's treatment
170936 - in accordance with understandings from case study on 070130,
170937 - ref SDS 6 2W58, showing the primary care physician at Kaiser submitted
170938 - a letter to Millie on 070119, saying he signed authorization for
170939 - Millie to get treatment at UCSF in the clinical trial. ref SDS 3 4R4M,
170940 - On 070124 Kaiser reported payment authorization issue resolved through
170941 - coordination with Medicare. ref SDS 4 6S6L  The next day on 070125
170942 - UCSF scheduled Millie for treatment and confirmed that payment
170943 - authorization was resolved. ref SDS 5 4Y5I
170945 -  ..
170946 - There is no reason for UCSF to send invoices to Kaiser, and then
170947 - Kaiser send out denial notices to UCSF and to Millie, then Medicare
170948 - makes a payment.  Conflicting procedures at Kaiser and UCSF indicates
170949 - confusion implementing Medicare regulations, which aligns with the
170950 - letter Millie received from the primary care physician at Kaiser on
170951 - 070119. ref SDS 3 4R4M
170952 -
170953 -     [On 071128 Kaiser Appeals Committee approved payment for Millie's
170954 -     care on referral to UCSF. ref SDS 15 JZ5R
170956 -  ..
170957 - Visited with Jackie in the cafeteria.  She suggested calling...
170958 -
170959 -        UCSF Medical Center Patient Financial Services
170960 -
170961 - ...the number is shown on each statement and invoice...
170962 -
170963 -        415 673 1113
170965 -  ..
170966 - Jackie further suggested contacting Doctor Rugo to notify the billing
170967 - department that payment for Millie's treatment at UCSF will be made by
170968 - Medicare for billings under Kaiser Senior Advantage.
170970 -  ..
170971 - Jackie indicated the doctor could notify UCSF staff to avoid this
170972 - unnecessary duplication.
170973 -
170974 -
170976 -  ..
1710 -
1711 -
1712 - 1005
1713 -
171301 - Called UCSF Patient Financial Services...... 415 673 1113
171302 -
171303 - Talked to Bob.
171305 -  ..
171306 - Millie has received a total of 30 invoices and statements from UCSF
171307 - the past month for services provided beginning in February.  Some of
171308 - these invoices show Medicare has paid UCSF.  Some of the invoices seek
171309 - payment from Millie, however there is no audit trail showing services
171310 - performed by UCSF.  There is no explanation of why Millie owes more
171311 - than Medicare has paid, or why any difference is not covered by her
171312 - insurance policy with Kaiser.
171314 -  ..
171315 - Bod said that Millie's case is very complex.
171316 -
171317 -     [On 070906 Doctor Rugo's letter concurs that Millie's case
171318 -     presents complicated issues. ref SDS 11 I49K
171319 -
171320 -     [On 070926 Karen at Kaiser assigned by primary care physician to
171321 -     facilitate solution of clinical trial payment issues notes
171322 -     Millie's case is very complex, which requires careful support for
171323 -     team care doctor patient partnership. ref SDS 13 QY5I
171325 -      ..
171326 -     [On 071128 Kaiser Appeals Committee approved payment for Millie's
171327 -     care on referral to UCSF. ref SDS 15 JZ5R
171329 -  ..
171330 - He explained that UCSF has sent Millie invoices with detailed charges
171331 - for each visit, which is assigned a unique statement number.
171333 -  ..
171334 - UCSF has submitted all billings to Kaiser in accordance with Kaiser's
171335 - original referral on 061230, ref SDS 1 3X6K, and confirmed by the
171336 - doctor on 070119. ref SDS 3 4R4M
171338 -  ..
171339 - For some reason not clear in the record, Kaiser has denied payment of
171340 - each invoice and told UCSF to bill Kaiser's Medicare department.  UCSF
171341 - has followed Kaiser's instruction, and Medicare has made payments.
171342 - UCSF has then billed Millie for the difference between amounts paid by
171343 - Medicare.
171344 -
171345 -     [On 071128 Kaiser Appeals Committee approved payment for Millie's
171346 -     care on referral to UCSF. ref SDS 15 JZ5R
171348 -  ..
171349 - Bob said that UCSF "Statements" do not show cumulative amount owed on
171350 - all charges to Millie, they only show amounts outstanding for each
171351 - visit, based on payments received from Medicare.  Neither invoices nor
171352 - statments show what items in UCSF's invoices that Medicare rejected,
171353 - and for which UCSF seeks payment from Millie.
171355 -  ..
171356 - Bob explained the most recent statement to illustrate problems to be
171357 - resolved...
171358 -
171359 -    Hospital Monthly Statement
171360 -    Please pay amount............................  $283.96
171361 -    Date due.....................................  070828
171362 -    Account number...............................  12764302
171363 -    ADM date.....................................  070503
171364 -    MRN..........................................  457772381
171365 -    Statement date...............................  070813
171367 -     ..
171368 -    Date       Description                         Amount
171369 -
171370 -               Previous balance.................. $1,191.45
171371 -    070802     Medicare payment..................      0.00
171372 -    070807     Medicare payment..................    756.14
171373 -    070807     Medicare payment..................  1,186.24-
171374 -    070807     Medicare payment..................  1,394.73
171375 -    070807     Medicare payment..................  1,872.12-
171377 -                ..
171378 -               Please pay this amount............   $283.96
171380 -  ..
171381 - Millie needs to know the total amount of UCSF's claim, and
171382 - justification of charges for UCSF services on referral from Kaiser.
171384 -  ..
171385 - With 30 or so invoices and statments from UCSF there is no evident way
171386 - to determine the total amount of UCSF's claim from inception on 070130
171387 - to date?
171389 -  ..
171390 - Bob said the amounts shown in UCSF billing documents are confusing,
171391 - because Medicare made payments shown by negative numbers, and then
171392 - withdrew payment, shown by positive numbers, and then made re-payments
171393 - shown by negative numbers that iteratively increased amounts covered
171394 - by Medicare.  This was done several times suggesting that someone at
171395 - UCSF contacted Medicare and they negotiated agreement that UCSF's
171396 - entitlement was greater than reflected by initial payments.  Bob does
171397 - not know who had those discussions nor the basis for payments by
171398 - Medicare.  At this time he cannot explain grounds for Millie to pay
171399 - more than Medicare found to be reasonable and necessary for services
171400 - rendered.
171402 -  ..
171403 - Bob advised that Millie is very lucky as a Medicare patient.  As a
171404 - national Cancer Center UCSF must treat Medicare patients.  The rates
171405 - Medicare pays UCSF is less than amounts UCSF charges other patients
171406 - for the same care.  This creates a lot of pressure to get additional
171407 - payment from Medicare patients through abuse of the co-insurance
171408 - process.
171409 -
171410 -     [On 070830 Bob seems to indicate that payments to UCSF are based
171411 -     on contractually agreed upon rates for standard services.
171412 -     ref SDS 9 WU5N
171414 -      ..
171415 -     [On 080730 UCSF billing spreadsheet illustrates PFFS Medicare
171416 -     program pays health care providers below market rates. ref SDS 9
171417 -     WP5I
171419 -      ..
171420 -     [On 070830 meeting with Bob Schwartz in UCSF accounting office
171421 -     review of current invoicing shows UCSF charging 56% for
171422 -     co-insurance rather than statutory requirement of 20%. ref SDS 9
171423 -     1G4H
171425 -      ..
171426 -     [On 070831 letter to UCSF confirms understandings. ref SDS 10 PX7R
171428 -      ..
171429 -     [On 070831 letter to UCSF confirms UCSF Kaiser Medicare unit go
171430 -     through several iterations of negotiations to increase payments to
171431 -     UCSF. ref SDS 10 PX8V
171433 -      ..
171434 -     [On 070917 research of Title 42 part 419.40 indicates 20% minimum
171435 -     rate of coinsurance for payment on various types (APC groups) of
171436 -     medical services are determined annually by Medicare which
171437 -     suggests these amounts are known in advance of entering treatment
171438 -     agreements. ref SDS 12 4Q3I
171440 -      ..
171441 -     [On 071018 AARP article explains many doctors and hospitals will
171442 -     not treat Medicare patients, ref SDS 14 UF4H; the UCSF billing
171443 -     spreadsheet on 080730 illustrates that the PFFS Medicare program
171444 -     pays health care providers below market rates. ref SDS 9 WP5I
171446 -  ..
171447 - Additionally, UCSF invoices conflict with understandings beween UCSF
171448 - and Kaiser in correspondence on 061230.  At that time, Kaiser agreed
171449 - to pay for standard of care not covered by the clinical trial.
171450 - ref SDS 1 3X6K  UCSF invoice for account number 12593370 covering
171451 - services on 070301 shows total charges of $4,549.49, and claims
171452 - entitlement to recover $1.240.96 from the patient.  Several items of
171453 - charges in this invoice, which for some reason are dated 070329,
171454 - rather than 070301 are for service code 6382448 described as....
171456 -         ..
171457 -        CHEMO ADM IV INF UP TO 1 HOUR............... $300
171458 -        COLLECT BLOOD VENOUS DEV.................... $171
171460 -  ..
171461 - These invoices require review for possible duplicate or at least
171462 - confusing charges.
171463 -
171464 -     [On 071128 Kaiser Appeals Committee approved payment for Millie's
171465 -     care on referral to UCSF. ref SDS 15 JZ5R
171467 -  ..
171468 - We considered meeting so that UCSF can make sense of the 30 or so
171469 - invoices Millie has received from UCSF.
171471 -  ..
171472 - Bob advised that he is located in the financial office where UCSF
171473 - billings are prepared located at 1st and Harrison in San Francisco.
171474 - He suggested that before meeting with him, it would help to visit the
171475 - Administration Office on the 1st floor at UCSF and talk to a financial
171476 - counselor who assists patients with payment issues.
171478 -  ..
171479 - While talking to Bob on Millie's cell phone, walked from the cafeteria
171480 - in the basement up to the 1st floor and met with...
171481 -
171482 -                         Yolanda Ramirez
171483 -                         Financial Counselor
171484 -                         Hospital Admissions and Registration
171485 -                         505 Parnassus Avenue M-140
171486 -                         San Francisco, CA  94143-0208
171487 -                         415 353 1906
171488 -                         yolanda.rameriz@ucsfmedctr.org
171490 -  ..
171491 - Yolanda normally works at the Parnassus Avenue office, but today she
171492 - is helping out here at the Divisadero Street office of UCSF.
171494 -  ..
171495 - Introduced Yolanda to Bob, and handed her the cell phone to continue
171496 - discussing Millie's account with Bob.  Yolanda reviewed with Bob all
171497 - of the 30 or so invoices received so far from UCSF.
171499 -  ..
171500 - After Yolanda and Bob reviewed the various invoices UCSF has sent to
171501 - Millie, Yolanda handed the cell phone back, and continued initial
171502 - discussion with Bob, where he indicated Millie's case is complex, per
171503 - above. ref SDS 0 RV6U
171505 -  ..
171506 - Bob said that based on his discussion with Yolanda, Millie should not
171507 - make any payments until UCSF investigates further.  He will prepare a
171508 - spreadsheet showing total amount UCSF claims is owed for medical
171509 - services UCSF has performed on referral from Kaiser for Millie
171510 - beginning on 070130 to date.  Millie needs to know how much UCSF seeks
171511 - to recover, and the justification.
171513 -  ..
171514 - Bob will send a letter today via email confirming that he will submit
171515 - a spreadsheet clarifying the total payments UCSF claims Millie owes,
171516 - and the grounds that justify UCSF entitlement.
171517 -
171518 -     [On 070830 Millie received a spreadsheet showing a total of
171519 -     $4,254.12 claimed by UCSF from Millie as of 070826. ref SDS 9 X16N
171521 -  ..
171522 - After talking to Bob, Yolanda confirmed Bob's advice that Millie make
171523 - no payments until UCSF submits support showing entitlement to payment
171524 - from Millie, rather than billing UCSF, as planned between UCSF and
171525 - Kaiser on 061230. ref SDS 1 3X6K
171526 -
171527 -     [On 071128 Kaiser Appeals Committee approved payment for Millie's
171528 -     care on referral to UCSF. ref SDS 15 JZ5R
171530 -  ..
171531 - Yolanda said she will investigate further by calling Barbara in the
171532 - Kaiser Outside Referral department, and follow up with Bob to get
171533 - UCSF's total claim against Millie and the basis for charges.
171534 -
171535 -     [On 070828 called Yolanda on results of her research. ref SDS 8
171536 -     X16N
171538 -  ..
171539 - Yolanda explained that she has medical insurance with Kaiser.  In her
171540 - experience working with Kaiser, when a referral is made in this case
171541 - to provide treatment the patient needs and is not available within
171542 - Kaiser, then Kaiser remains liable for costs of the treatment the same
171543 - as if the patient was treated within Kaiser.
171545 -  ..
171546 - Yolanda submitted her business card, and asked to get a copy of Bob's
171547 - letter when it is received later today, so she can follow up to review
171548 - his spreadsheet showing UCSF's claim.
171549 -
171550 -
171552 -  ..
1716 -
1717 -
1718 - 1756
1719 -
171901 - Millie received ref DRT 1 0001 from Bob confirming planning today for
171902 - expediting payment based on Bob submitting a spreadsheet showing the
171903 - total amount UCSF claims Millie owes for treatment, and providing
171904 - justification for charges.  Bob sent a copy to Yolanda, as she
171905 - requested, per above. ref SDS 0 X183
171906 -
171907 -
171908 -
171909 -
171910 -
171911 -
171912 -
171913 -
171914 -
171915 -
1720 -