THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: August 29, 2007 01:28 PM Wednesday; Rod Welch

Millie met with Barbarba and Arlette at Kaiser in Walnut Creek.

1...Summary/Objective
2...Kaiser Member Services Investigating Kaiser Failure Pay Referral Costs
........Section 2: What's Covered Medicare
........Labs Blood Tests Clinical Trials Paid by Medicare
........Coinsurance May Apply for Treatment in Clinical Trials


..............
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CONTACTS 

SUBJECTS
Clinical Trials Blood Tests Coinsurance  Rsearch UCSF Medical Center

2003 -
2003 -    ..
2004 - Summary/Objective
2005 -
200501 - Follow up ref SDS 6 0000.
200502 -
200503 -
200504 -
200506 -  ..
2006 -
2007 -
2008 - Progress
2009 -
200901 - Kaiser Member Services Investigating Kaiser Failure Pay Referral Costs
200902 -
200903 - Follow up ref SDS 7 T06I.
200904 -
200905 - Millie went to the 4th floor and found the office for Kaiser Member
200906 - Services Department.
200908 -  ..
200909 - Met with Barbara.
200911 -  ..
200912 - Barbara reviewed the invoices and statements Millie has received from
200913 - UCSF for treating her cancer in a clinical trial.  She saw the
200914 - spreadsheet Bob Schwartz prepared summarizing the UCSF claim that
200915 - Millie owes over $4K as of 070826 for getting treatment in a clinical
200916 - trial.
200918 -  ..
200919 - Explained background discussions with Bob on 070823 when he reported
200920 - that UCSF billings to Millie are complex.  The invoices are difficult
200921 - to reconcile amounts claimed with services performed by UCSF.
200922 - ref SDS 6 RV6U  Yesterday, in a telephone call, Bob advised that UCSF
200923 - feels Millie should make an independent review of Medicare
200924 - requirements in order to understand UCSF's claim. ref SDS 7 WN3H
200926 -  ..
200927 - Barbara also examined the many letters Millie has received from Kaiser
200928 - saying payment to UCSF for Millie's treatment is denined because the
200929 - physician has not submitted authorization.
200931 -  ..
200932 - Discussed background on 061230 letter from Millie's primary care
200933 - physician making referral arrangement with UCSF, and giving notice
200934 - that Kaiser would pay for costs not paid by the trial. ref SDS 2 3X6K
200935 - Subsequently, on 070119 the primary care physician notified Millie in
200936 - a letter than he submitted authorization for Millie to get treatment
200937 - on referral to UCSF Medical Center. ref SDS 3 4R4M
200939 -  ..
200940 - Barbara said Millie's case is complicated and so she has to do some
200941 - research by calling various sources about Millie's obligations in this
200942 - case.  Barbara suggested that Millie go for a walk, do some shopping
200943 - for an hour or so while Barbara investigates her case.
200944 -
200946 -  ..
2010 -
2011 -
2012 - 1447
2013 -
201301 - Millie went to the Oncology Department on the 2nd floor and asked to
201302 - meet with Arlette.
201304 -  ..
201305 - Arlette came into the customer waiting lobby and spoke with Millie.
201307 -  ..
201308 - Millie showed Arlette the spreadsheet from UCSF claiming Millie owes
201309 - over $4K, and that UCSF called yesterday to say the amount is now even
201310 - bigger. ref SDS 7 PG57
201312 -  ..
201313 - Arlette seemed very surprised.  She said they send patients on
201314 - referral all the time for treatment they need, and Kaiser takes care
201315 - of the cost.  This aligns with Arlette's letter to Millie on 060809
201316 - reporting extensive exerience making referrals for treatments.
201317 - ref SDS 1 NT9X
201319 -  ..
201320 - Arlette seemed to indicate that Millie is the first patient referred
201321 - to an outside service provider since new Medicare regulations went to
201322 - affect.  This aligns with the letter Millie received from the primary
201323 - care physician on 070119. ref SDS 3 4R4M
201324 -
201325 -     [On 070831 Arlette commended for assisting Kaiser and UCSF develop
201326 -     procedures to implement confusing regulations for payment of
201327 -     patient care on referral. ref SDS 9 P14W
201329 -  ..
201330 - Arlette will try to find regulations that govern Millie's treatment at
201331 - UCSF in the clinical trial, and Kaiser's procedures for making
201332 - payments.
201333 -
201334 -     [On 070906 Millie received letter from Arlette transmitting Kaiser
201335 -     internal policy on clinical trials. ref SDS 10 HC4I
201337 -      ..
201338 -     [On 071002 Mark Manfriede seems to indicate that Millie is the
201339 -     first patient who has been processed by CMS under new Medicare
201340 -     rules for clinical trials. ref SDS 14 GJ6M
201341 -
201342 -
201343 -
201345 -  ..
2014 -
2015 -
2016 - 1517
2017 -
201701 - Millie visited Barbara again on the 4th Floor in Member Services
201702 - Department.
201704 -  ..
201705 - Babara asked Millie about the terms and conditions of service Millie
201706 - signed at UCSF for getting treatment in the clinical trial?
201708 -  ..
201709 - Millie showed Barbara a copy of the document Millie signed on 070412
201710 - 0830.  Paragraph 4, Financial Agreement says...
201711 -
201712 -        The undersigned accepts responsibility for all deductibles and
201713 -        co-payments that may be required by the patient's health
201714 -        insurance, including Medicare.
201716 -  ..
201717 - Millie's commitment to UCSF aligns with Kaiser's commitment on 061230
201718 - to pay for costs of her treatment in the clinical trial, per above.
201719 - ref SDS 0 EF9I
201721 -  ..
201722 - Barbara said that her research shows the case is very complex because
201723 - multiple organizations, including Kaiser, UCSF, Medicare, and CMS are
201724 - all involved.  Each have complex procedures and are operating on
201725 - Millie's long, complicated patient history of treatment for cancer by
201726 - Kaiser, shown in the record on 070524. ref SDS 5 LU3J
201728 -  ..
201729 - Barbara submitted a Kaiser Member Services document on Medicare which
201730 - she feels may apply to Millie's case...
201731 -
201732 -        Section 2:  What's Covered Medicare
201733 -        Labs Blood Tests Clinical Trials Paid by Medicare
201734 -        Coinsurance May Apply for Treatment in Clinical Trials
201736 -         ..
201737 -        This document shows Medicare Part B pays for clincial
201738 -        laboratory services, including blood tests. ref OF 1 YI7W
201739 -
201740 -            [On 070830 reported Barbara's findings to Bob Schwartz in
201741 -            UCSF accounting who explained recent billings. ref SDS 8
201742 -            RW4J
201744 -             ..
201745 -            [On 070927 Kaiser EOC Section 7 says that laboratory blood
201746 -            tests are paid by Medicare. ref SDS 13 1F67
201748 -             ..
201749 -            [On 071010 UCSF letter seems to say Millie is not charged
201750 -            coinsurance on blood tests; refusal to submit details
201751 -            showing how charges are calculated, raises questions of
201752 -            billing irregularities. ref SDS 15 T64J
201754 -         ..
201755 -        Clinical trials are paid by Medicare to help doctors and
201756 -        researchers find better treatments and reduce costs.
201757 -        ref OF 1 YI8R
201759 -         ..
201760 -        Coinsurance and deductables may apply. ref OF 1 YI9S
201762 -  ..
201763 - Millie asked how Kaiser informs patients about the scope and cost of
201764 - "coinsurance" since nobody has ever said anything about this?  How
201765 - much is it?  Who is paid?  How does anyone find out?
201767 -             ..
201768 -            [On 070906 seems to align with internal Kaiser guidance
201769 -            received from Arlette. ref SDS 10 647I
201771 -             ..
201772 -            [On 070909 Barbara's research on clinical trials submitted
201773 -            to Kaiser and UCSF to resolve payment issues. ref SDS 11
201774 -            NW5N
201776 -             ..
201777 -            [On 070927 Kaiser EOC Section 7 dated 070101 for Senior
201778 -            Advantage page 68 describes 20% coinsurance for clinical
201779 -            trials participating without doctor's referral, ref SDS 13
201780 -            1F67, is clarified by Kaiser's documentation today that
201781 -            coinsurance may apply, since EOC section 2 says Kaiser must
201782 -            pay for prescribed treatment. ref SDS 13 1F67
201784 -  ..
201785 - Barbara said she has never heard of coincurance.  She cited Kaiser's
201786 - website telling customers to ask clinical trial providers about it,
201787 - as follows...
201788 -
201789 -        "Medicare will pay for many, but not all, services
201790 -        associated with qualifying Clinical Trials.  You should ask
201791 -        the Clinical Trial provider if the Clinical Trial qualifies
201792 -        for Medicare payments, and what Medicare coinsurance and
201793 -        other out-of-pocket expenses you will have to pay."
201794 -
201795 -            [On 070830 discussed Kaiser documentation received today
201796 -            with Bob at UCSF accounting department, ref SDS 8 LF5L, who
201797 -            indicated there is no evident correlation between medical
201798 -            services provided by UCSF and amounts billed to Millie.
201799 -            ref SDS 8 WU5N
201801 -             ..
201802 -            [On 070831 letter to UCSF confirms discussion of Kaiser
201803 -            documentation on coinsurance. ref SDS 8 LF5L
201805 -             ..
201806 -            [On 090529 1109 Millie asks Doctor Rugo for the cost to
201807 -            participate in the MPA clinical trial at UCSF. ref SDS 16
201808 -            0M6Y
201810 -  ..
201811 - Millie related again that on 061230 her doctor discussed payments with
201812 - UCSF and agreed Kaiser would pay all costs not covered by the trial.
201813 - ref SDS 2 3X6K  Payment authorization was discussed extensively for
201814 - several days between Kaiser and UCSF experts.  Millie was notified on
201815 - 070126 that the issue was resolved, and nobody advised of additional
201816 - charges beyond monthly insurance premiums to Kaiser.  Nobody disclosed
201817 - changes to the agreement between Kaiser and UCSF on 061230; and nobody
201818 - said anything during those discussions about coinsurance. ref SDS 4
201819 - F175
201821 -             ..
201822 -            [On 070917 research shows Kaiser tells customers to ask the
201823 -            clinical trial provider how much will be charged for
201824 -            coinsurance. ref SDS 12 416K
201826 -             ..
201827 -            [On 070927 Kaiser EOC for Senior Advantage page 68
201828 -            describes 20% coinsurance for clinical trials participating
201829 -            without doctor's referral. ref SDS 13 1F67  EOC section 2
201830 -            says Kaiser must pay for prescribed treatment. ref SDS 13
201831 -            1F67
201833 -  ..
201834 - Barbara said she is sorry there nothing more Member Services can do
201835 - to assist Millie.
201837 -             ..
201838 -            [On 070909 Barbara's research on clinical trials submitted
201839 -            to Kaiser and UCSF to resolve payment issues. ref SDS 11
201840 -            NW5N
201841 -
201842 -
201843 -
201844 -
201845 -
201846 -
201847 -
201848 -
2019 -