THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: August 30, 2007 08:07 AM Thursday;
Meet UCSF review policy procedures on billings for Millie's treatments
2...$10,000 UCSF Claim Annual Clinical Trial Treatments 56% Medicare Payments
3...56% Medicare Payments UCSF Charging Coinsurance $10,000 Clinical Trial
4...Clinical Trial Coinsurance 56% Medicare Payments UCSF Charging $10,000
5...Claim Not Supported by Record of Services Provided Invoice Confusing
6...Confusing Invoice No Correlation UCSF Services and Claim Against Millie
7...Negotiate Medicare Payments for Clinical Trial Services
8...Doctor Assigns Code for Billing Medicare on Established Rate Schedule
9...Justification Charges Entitlement Predicate Charity Collection Efforts
10...Collection Agencies Charities Deferred Pending Justification Charges
11...Charity Appeals Payment UCSF Pending Justification of Charges
12...Kaiser May be Rejecting Medicare Payment for Blood Tests
13...Blood Tests Lab Costs Routine Care Trials Kaiser Charges Millie
14...Account Balance Transfer Charges Not Justified Invoice Confusing
15...Invoice Confusing Account Balance Transfer Charges Not Justified
16...Chemotherapy Paid by Clinical Trial Double Billed in Invoices
17...Invoices No Correlation Medical Services and Charges to Patient
18...Lab Blood Tests Essential for Realtime Monitor Chemotherapy Care
19...Clinical Trial Referrals Expand Treatments Integral Oncology Practice
20...$10K Claim Treatment Clinical Trial Conflicts with Patient History
21...Double Dipping Savings Not Justified Kaiser Responsible Cost Standard of Care
22...Clinical Trials Prescribed by Kaiser Routinely Charge No Coinsurance
23...Self-referral Not Supported by Patient History; Kaiser Prescribes
24...Case Study Kaiser Routinely Prescribed Treatment Clinical Trials
25...Referrals Kaiser Routinely Coordinates Pays All Costs Patient Never Sees Invoice
26...Insurance Senior Advantage Since 2002 Why Extra Charges in 2007??
27...Documentation at UCSF Shows Kaiser Referred Millie for Treatment
28...Kaiser's Self-referral Theory Conflicts Patient History
29...Patient Benefits Do Not Shield Kaiser from Paying for Prescribed Care
30...Medicare Breaks Trust and Reliance between Patient and Doctor
31...Coinsurance Interim Payment Doctor Visits Pending Justification
32...Payment Dispute UCSF and Kaiser Resolution Objectives
33...Goals for Resolution Dispute between Kaiser and UCSF
34...UCSF Treatments Effective Continue Patient Objective Goals
35...4 Problems Interjecting Medicare Between Kaiser and Patient
36...Patient Agreement UCSF Obligations Discharged by Kaiser Insurance
37...Coinsurance Not Owed Kaiser Pays Costs Not Covered by Clinical Trial
38...Kaiser Says Customers May Be Charged Coinsurance for Clinical Trials
39...Doctor Visits Copayments Requested by UCSF Conflicts Clinical Trial
40...UCSF Requests Copayments Doctor Visits Identified as $101
41...Patient Agrees Copayments for Doctor Visits Same as at Kaiser
Click here to comment!
0201 - UCSF Medical Center
020101 - Mr. Robert Zvi Schwartz, MPH
020102 - Patient Financial Consultant
020104 - Patient Financial Services
UCSF Cannot Justify Claim Against Millie for Treatment Clinical Tria
2703 - ..
2704 - Summary/Objective
270501 - Follow up ref SDS 31 0000. ref SDS 30 0000.
270503 - Bob was very helpful discussing UCSF's claim against Millie for
270504 - Medicare coinsurance. He submitted a new spreadsheet increasing the
270505 - amount to approximately $10K per year. ref SDS 0 X16N This
270506 - calculates to 56% of the amount Kaiser's Medicare unit has paid on
270507 - UCSF billings. This 36% more than 20% Medicare authorizes provides to
270508 - charge patients for clinical trial care. ref SDS 0 7X5G Bob confirmed
270509 - today there is no correlation between any amount UCSF claims is
270510 - "patient responsibility" and cost of medical services listed in UCSF
270511 - invoices. Bob indicated Kaiser's Medicare unit may be designating
270512 - costs of blood tests as patient responsibility because Kaiser wants
270513 - payment for performing the work, and does not want to pay UCSF for
270514 - doing lab work. ref SDS 0 T149 Review during the meeting shows blood
270515 - tests are routine care covered by Medicare. ref SDS 0 636H Bob
270516 - further noted that the only reason Millie is receiving a lot of
270517 - invoices that add up to about $10K more per year than Millie's
270518 - insurance premiums is because her treatment is being performed at UCSF
270519 - rather than at Kaiser. If the same work were performed at Kaiser,
270520 - Millie would not be faced with a claim for treatment on clinical
270521 - trial. ref SDS 0 NQ3F Case study shows Kaiser has routinely
270522 - prescribed treatment for Millie through clinical trial referral and
270523 - never claimed recovery of coinsurance. ref SDS 0 LQ5I Recommended
270524 - UCSF meet with Kaiser to develop a referral coordination plan that
270525 - guides work and payment responsibilities for all the parties, and
270526 - gives the patient notice of any extra charges before costs are
270527 - incurred. ref SDS 0 VT7G UCSF requested interim payment of
270528 - coinsurance for doctor visits, based on Bob's markup of the new
270529 - spreadsheet received today and identifying amounts to pay for doctor
270530 - visits. ref SDS 0 W06L Coinsurance presents four (4) issues that
270531 - require resolution. ref SDS 0 T94O UCSF will submit justification
270532 - showing entitlement to payment of coinsurance in this case.
270533 - ref SDS 0 V373
270535 - [On 070831 letter to Jackie for copy to Doctor Rugo at UCSF, and
270536 - copy to Doctor Johnson at Kaiser confirming understandings from
270537 - meeting with Bob today. ref SDS 34 PX5U
270539 - ..
270540 - [On 070904 Millie letter to Doctor Rugo requests assistance
270541 - resolving billing problems between Kaiser and UCSF.
270542 - ref SDS 35 G15I
270544 - ..
270545 - [On 070906 Millie submitted interim payment to UCSF for
270546 - coinsurance, subject to justification from UCSF. ref SDS 36 EB3P
270548 - ..
270549 - [On 070917 UCSF revised claim reduced to $1,500, annualized
270550 - reduction from $10K down to about $2K per year, ref SDS 38
270551 - WO4O, which more than doubles copayment costs typically
270552 - incurred for the work involved. ref SDS 38 G68H
270554 - ..
270555 - [On 071006 Kaiser proposes Appeals Committee review of failure to
270556 - perform requirements of Millie's referral to UCSF for treatment.
270557 - ref SDS 45 0001
270559 - ..
270560 - [On 071006 UCSF billing irregularities identified. ref SDS 45 454M
270562 - ..
270563 - [On 071024 propose meeting to correct problems with billings and
270564 - agree on interim payment. ref SDS 53 AI5G
270566 - ..
270567 - [On 071026 UCSF billing irregularities reviewed. ref SDS 54 X18J
270569 - ..
270570 - [On 071026 UCSF demands payment of claim in 1 week that conflicts
270571 - with requirements for Kaiser to pay UCSF, and presents confusing
270572 - and unjustified charges. ref SDS 54 SU5V
270574 - ..
270575 - [On 071031 Millie gets notice dated 071026 UCSF plans referral to
270576 - collection agency for payment of $202.65 on Kaiser referral
270577 - account 12493370, ref SDS 57 KK4I, revised 070830, ref SDS 33
270578 - 4P8K, and revised again on 070917, ref SDS 38 MK4H; no indication
270579 - of UCSF collection efforts against Kaiser; separate notice dated
270580 - 071027 and also received 071031 UCSF says Millie's treatment for
270581 - cancer ordered by Kaiser will be terminated if UCSF does not
270582 - receive payment of $202.65. ref SDS 57 KM8J
270589 - ..
2708 - Progress
270901 - $10,000 UCSF Claim Annual Clinical Trial Treatments 56% Medicare Payments
270902 - 56% Medicare Payments UCSF Charging Coinsurance $10,000 Clinical Trial
270903 - Clinical Trial Coinsurance 56% Medicare Payments UCSF Charging $10,000
270905 - Follow up ref SDS 32 EF7L.
270907 - Background - on 061230 Kaiser arranged with UCSF to treat Millie for a
270908 - 3rd relapse of inflammatory breast cancer (IBC). ref SDS 15 PN5X
270909 - Kaiser agreed to pay UCSF any costs not covered by the clinical trial.
270910 - ref SDS 15 3X6K On 070105 the doctor notified Millie during a meeting
270911 - at Kaiser that her treatment was changed from Navelbine to cetuximab
270912 - and carboplatin on referral to UCSF. ref SDS 17 PK68
270914 - ..
270915 - On 070823 Millie reported having suddenly received a rash of invoices
270916 - from UCSF backdated to January. ref SDS 30 X16N Review showed
270917 - conflict with Kaiser's duty to pay for prescribed treatment, no
270918 - correlation between charges and services, duplication of charges,
270919 - confusing calculations (see example below, ref SDS 0 4P8K, and no
270920 - basis for determining the total amount claimed by UCSF. ref SDS 30
270921 - 1Y9N
270923 - ..
270924 - At that time, on 070823 Bob advised in a telephone call that UCSF
270925 - would submit a spreadsheet with UCSF's total claim to date against
270926 - Millie. ref SDS 30 PQRY A week later on 070828 Millie received a
270927 - spreadsheet showing a total claim of over $4,000. ref SDS 31 T06I Bob
270928 - also called later in the day and said to disregard the spreadsheet,
270929 - because new charges need to be added. ref SDS 31 PG57 At that time,
270930 - scheduled a meeting for today so that UCSF can explain the basis of
270931 - charges, and the total being claimed against Millie. ref SDS 31 PG60
270933 - ..
270934 - As discussed on 070828, during the meeting today Bob submitted a new
270935 - spreadsheet...
270937 - g: 08 02 04 60 07 08 3001a.xls
270939 - ..
270940 - The new cost analysis received from Bob today lists additional amounts
270941 - UCSF claims Millie owes for getting treatment with cetuximab.
270942 - ref SDS 31 T14N Bob said this new spreadsheet reflects more invoices
270943 - and statements UCSF has sent to Millie since last week on 070823.
270944 - ref SDS 30 X16N These invoices now number more than 70 documents, and
270945 - calculate to a rate of 56% billed to Millie for coinsurance against
270946 - amounts Kaiser has paid to UCSF through Medicare, as follows...
270948 - ..
270949 - The UCSF spreadsheet received today shows...
270951 - UCSF Facility Billing
270953 - Date: September 30, 2007
270955 - <------- UCSF Services ------> <----------- Insurance ---------> Patient Rate
270956 - Date Account Charges Payment Adjustment Pending Responsibility Percentage
270957 - 20070130 12571560 $101.00 $111.54 -$38.42 $27.88 25.00%
270958 - 20070201 12575680 $2,997.00 $752.12 $1,314.86 $910.02 120.99%
270959 - 20070201 12575738 $101.00 $89.02 -$10.28 $22.26 25.01%
270960 - 20070301 12575761 $101.00 $89.02 -$10.28 $22.26 25.01%
270961 - 20070208 12588856 $101.00 $111.54 -$38.42 $27.88 25.00%
270962 - 20070301 12593370 $4,549.49 $1,776.54 $1,531.99 $1,240.96 69.85%
270963 - 20070315 12720616 $101.00 $111.54 -$38.42 $27.88 25.00%
270964 - 20070329 12762558 $101.00 $111.54 -$38.42 $27.88 25.00%
270965 - 20070426 12762597 $1,049.59 $569.74 $323.78 $22.26 3.91%
270966 - 20070510 12762609 $101.00 $111.54 -$38.42 $27.88 25.00%
270967 - 20070524 12762615 $1,094.59 $658.03 $341.35 $22.26 3.38%
270968 - 20070405 12763636 $2,114.32 $698.82 $983.38 $432.12 61.84%
270969 - 20070503 12764302 $3,342.32 $1,186.24 $1,872.12 $283.96 23.94%
270970 - 20070419 12880922 $315.07 $125.96 $161.23 $27.88 22.13%
270971 - 20070607 12997853 $101.00 $111.54 -$38.42 $27.88 25.00%
270972 - 20070621 12997859 $948.59 $143.72 $749.80 $55.07 38.32%
270973 - ..
270974 - 20070607 12997886 $3,489.59 $821.70 $1,625.77 $1,042.17 126.83%
270975 - ..
270976 - 20070705 12997900 $3,103.00 $3,103.49 Not yet determined
270977 - 20070802 12997919 $3,398.09 $3,398.09 Not yet determined
270979 - ..
270980 - Totals..............$27,209.65 $7,580.15 $8,653.20 $6,501.09 $4,248.50
270982 - ..
270983 - TOTAL PATIENT RESPONSIBILITY AS OF 20070826........................ $4,254.12 56.05%
270985 - [On 071018 AARP article explains many doctors and hospitals
270986 - will not treat Medicare patients, ref SDS 51 UF4H; the UCSF
270987 - billing above illustrates that the PFFS Medicare program
270988 - pays health care providers below market rates. ref SDS 0
270989 - WP5I
270991 - ..
270992 - [On 090604 1534 60% bankruptcies due to medical billings,
270993 - Reuters article reports study. ref SDS 66 QW5H
270995 - ..
270996 - Charging 56% for coinsurance, nearly 300% more than 20% authorized by
270997 - statute, aligns with Bob's report on 080823 that UCSF receives less
270998 - payment from Medicare than UCSF charges other customers. ref SDS 30
270999 - P28L This creates pressure on the accounting department to be
271000 - creative with financial engineering that overcharges "soft targets" of
271001 - elderly, fragile Medicare customers for coinsurance, who are unable to
271002 - navigate massive complex billings, nor to notify the accounting
271003 - department to submit corrected and comprehensible billings based on
271004 - services provided.
271006 - ..
271007 - [On 070917 research of Title 42 part 419.40 indicates 20%
271008 - minimum rate of coinsurance for payment on various types
271009 - (APC groups) of medical services are determined annually by
271010 - Medicare which suggests these amounts are known in advance
271011 - of entering treatment agreements. ref SDS 38 4Q3I
271013 - ..
271014 - [On 071018 AARP article explains many doctors and hospitals
271015 - will not treat Medicare patients, ref SDS 51 UF4H; the UCSF
271016 - billing above illustrates that the PFFS Medicare program
271017 - pays health care providers below market rates. ref SDS 33
271018 - WP5I
271020 - ..
271021 - [On 081007 1130 over-billings for health care shown by
271022 - Richard's experience being billed $300,000 for 10-days care
271023 - in the hospital to recover from blood clot. ref SDS 59 IV6J
271025 - ..
271026 - [On 081016 Millie's doctor at UCSF had similar experience
271027 - getting overcharged for medical services, and then harassed
271028 - for 2 years. ref SDS 60 7N7H
271030 - ..
271031 - [On 090223 0947 dentist billed $17,000 for son's
271032 - examination in hospital Emergency Department for 3 hours
271033 - and for which no treatment was required. ref SDS 64 K06O
271035 - ..
271036 - UCSF requests a new total amount today of $4,254.12, as of 070826,
271037 - which is 56% of Medicare payments ($7,580.15) shown in the UCSF
271038 - spreadsheet. Bob noted the bottom of the list has 2 "pending" charges
271039 - totaling $6,501.09, which have not been reviewed by Medicare to
271040 - determine how much UCSF will bill Millie. ref SDS 0 OT8M He said that
271041 - Millie will likely be billed an additional $1,500 after UCSF
271042 - negotiates with Kaiser's Medicare people, in accordance with
271043 - procedures discussed last week on 070823. ref SDS 30 RW3R Since that
271044 - time, Millie has continued to receive invoices, statements, and
271045 - documents from UCSF and Kaiser aimed at getting Millie to pay over
271046 - 500% more for treatment than agreed through her insurance coverage, as
271047 - discussed in correspondence between Kaiser and UCSF on 061230.
271048 - ref SDS 15 3X6K
271050 - [On 070906 Kaiser's guidance calls for clinical trial provider to
271051 - disclose costs before starting treatments in a clinical trial,
271052 - ref SDS 36 SC71; clinical trial director did not know patient
271053 - would be charged out-of-pocket expenses. ref SDS 36 I49K
271055 - ..
271056 - Based on UCSF's current claim of about $6K for 3 months of treatment,
271057 - a rough estimate of the UCSF claim projected for an entire year of
271058 - weekly treatments required by the clinical trial protocol is about
271059 - $24K added to about $2K per year she already pays for health
271060 - insurance. More problematic is UCSF billing practice of demanding
271061 - payment for services not performed, indicating that without careful
271062 - scrutiny, UCSF may claim upwards of $40K per year. This conflicts
271063 - with Kaiser's agreement on 061230 to pay any costs not covered by the
271064 - clinical trial, ref SDS 15 3X6K, and also with Doctor Rugo's planning
271065 - on 070130 to make financial arrangements that would avoid Millie
271066 - getting a "big bill." ref SDS 21 LY9H
271068 - [On 070917 UCSF revised claim reduced to $1,500, annualized
271069 - reduction from $24K down to about $2K per year, ref SDS 38
271070 - WO4O, which more than doubles copayment costs typically
271071 - incurred for the work involved. ref SDS 38 G68H
271073 - ..
271074 - [On 071006 Millie received additional billings from UCSF that
271075 - indicate total charges would be in the range of $30K - $60K per
271076 - year. ref SDS 45 PRWW
271078 - ..
271079 - [On 071128 Kaiser Appeals Committee approved payment for
271080 - Millie's care on referral to UCSF. ref SDS 58 JZ5R
271083 - ..
271084 - Claim Not Supported by Record of Services Provided Invoice Confusing
271085 - Confusing Invoice No Correlation UCSF Services and Claim Against Millie
271086 - Negotiate Medicare Payments for Clinical Trial Services
271087 - Doctor Assigns Code for Billing Medicare on Established Rate Schedule
271089 - Follow up ref SDS 30 RV6U.
271091 - UCSF lists a "Patient Bill of Rights" on every floor of the hospital
271092 - where Millie is treated at 1600 Divisadero Street in San Francisco.
271093 - UCSF invoices fail the first requirement that "information must be
271094 - complete and clear," shown by the example discussed today, listed
271095 - below. ref SDS 0 4P8K In the past few weeks, the patient has received
271096 - over 30 of these documents for only a few months of treatment,
271097 - reported on 070823. ref SDS 30 X16N
271099 - ..
271100 - During the meeting today Bob confirmed understandings from the call on
271101 - 070823 that UCSF cannot identify any item of cost in UCSF invoices and
271102 - statements which correlate with any payments UCSF seeks from Millie.
271103 - He said that UCSF bills Millie for amounts calculated by Kaiser's
271104 - Medicare accountants, and the basis of these calculations is not
271105 - provided by Kaiser, ref SDS 30 RV6U, and have no evident correlation
271106 - to any medical services UCSF has performed for the patient, shown by
271107 - example below, ref SDS 0 4P8K, and considered again discussing (below)
271108 - unsupported coinsurance charges. ref SDS 0 XZ5L
271110 - ..
271111 - Bob further advised that UCSF has agreed to accept payment for
271112 - treating Medicare patients at previously agreed prices for various
271113 - services. The doctor assigns a code to classify work according to
271114 - establshed rate schedule. This understanding seems conflicting with
271115 - the call on 070823 saying that UCSF and Kaiser's Medicare unit
271116 - negotiate increased payments to UCSF. If prices are set by contract,
271117 - it seems unclear why several iterations of payments, negotiations, and
271118 - repayments would be required, as presented during the call with Bob on
271119 - 070823. ref SDS 30 NN71
271121 - [On 070831 letter to UCSF confirms understandings on billing
271122 - procedures. ref SDS 34 PY6X
271124 - ..
271125 - [On 070906 UCSF Clinical Trial Director confirms Kaiser made the
271126 - referral and the patient was not notified of extra charges for
271127 - coinsurance, because nobody knew anything about this issue when
271128 - treatment was started on 070202. ref SDS 36 I49K
271130 - ..
271131 - [On 070917 UCSF request for interim payment of conisurnace on
271132 - doctor visits charged at $101.00 example of no correlation between
271133 - charges and services performed by UCSF. ref SDS 38 WO6X
271135 - ..
271136 - [On 070917 research of Title 42 part 419.40 indicates 20% minimum
271137 - rate of coinsurance for payment on various types (APC groups) of
271138 - medical services are determined annually by Medicare which
271139 - suggests these amounts are known in advance of entering treatment
271140 - agreements. ref SDS 38 4Q3I
271142 - ..
271143 - [On 070917 limitations on annual amount of coinsurance patients
271144 - owe under Medicare. ref SDS 38 TN4N
271146 - ..
271147 - [On 071011 Millie asks doctor for assistance to explain confusing
271148 - billings, and get total amount UCSF claims is owed for clinical
271149 - trial services. ref SDS 47 K64W
271151 - ..
271152 - Bob indicated he was not aware that Millie has received 30 or so
271153 - invoices from UCSF and an equal number of letters from Kaiser saying
271154 - payment to UCSF is denied, indicating that UCSF has billed Kaiser.
271155 - When Kaiser refused payment, UCSF sent a bill to Millie as an easier
271156 - target for collection.
Collection Billings Erroneous Charges Medical Services Entitlement P
550401 - ..
550402 - Justification Charges Entitlement Predicate Charity Collection Efforts
550403 - Collection Agencies Charities Deferred Pending Justification Charges
550404 - Charity Appeals Payment UCSF Pending Justification of Charges
550406 - Bob explained UCSF's standard operating procedure for late payments
550407 - from cancer patients is to hire collection agencies trained in getting
550408 - money from people. He asked if Millie owns a home, and indicated that
550409 - for destitute customers, UCSF can appeal to charity organizations to
550410 - fill the gap between UCSF billings prepared by Kaiser and the amount
550411 - Kaiser is willing to pay. Bob asked if UCSF should start paperwork on
550412 - seeking charity to supplement revenues in this case?
550414 - [On 070917 UCSF revised claim reduced to $1,500, annualized
550415 - reduction from $10K down to about $2K per year, ref SDS 38
550416 - WO4O, which more than doubles copayment costs typically
550417 - incurred for the work involved. ref SDS 38 G68H
550419 - ..
550420 - Bob decided that complexity of this case, noted by UCSF on 070823,
550421 - ref SDS 30 RV6U, and by Barbara Latino at Kaiser Member Services
550422 - yesterday, ref SDS 32 GK5L and ref SDS 32 RA85, requires deferring
550423 - charity appeals until UCSF has time to justify charges against Millie,
550424 - and can review entitlement to payment from Kaiser for the referral
550425 - transaction with UCSF which Kaiser initiated to meet obligations for
550426 - Millie's care, discussed further below. ref SDS 0 T94O Patient
550427 - history in this case shows collection efforts should be directed
550428 - toward Kaiser rather than Millie.
550430 - [On 071009 Kaiser proposes payment assistance to Millie
550431 - based on alleged "information" from unnamed sources at
550432 - Kaiser that Millie owes coinsurance, ref SDS 46 N88P, and
550433 - without any showing of efforts to collect from Kaiser.
550434 - ref SDS 46 NU3M
550436 - ..
550437 - [On 071024 propose meeting to correct problems with
550438 - billings and agree on interim payment. ref SDS 53 AI5G
550440 - ..
550441 - [On 071026 UCSF billing irregularities reviewed.
550442 - ref SDS 54 X18J
550444 - ..
550445 - [On 071026 UCSF demands payment of claim in 1 week that
550446 - conflicts with requirements for Kaiser to pay UCSF, and
550447 - presents confusing and unjustified charges. ref SDS 54 SU5V
550449 - ..
550450 - [On 071031 Millie receives notice dated 071026 UCSF has
550451 - scheduled assignment to a collection agency for payment of
550452 - account 12493370 in the amount of $202.65, ref SDS 57 KK4I,
550453 - reviewed on 070830, ref SDS 33 4P8K, and revised again on
550454 - 070917, ref SDS 38 MK4H; there is no indication of UCSF
550455 - collection efforts against Kaiser who ordered the work; and
550456 - in a separate notice the next day on 071027 UCSF threatens
550457 - that Millie's treatment for cancer ordered on referral by
550458 - Kaiser will be terminated if UCSF does not receive payment
550459 - from Millie, which is owed by Kaiser. ref SDS 57 KM8J
550461 - ..
550462 - [On 071031 Millie receives notice dated 071026 UCSF plans
550463 - referral to collection agency for payment of $202.65 on
550464 - Kaiser referral account 12493370, ref SDS 57 KK4I, revised
550465 - 070830, ref SDS 33 4P8K, and revised again on 070917,
550466 - ref SDS 38 MK4H; no indication of UCSF collection efforts
550467 - against Kaiser; separate notice dated 071027 and also
550468 - received 071031 UCSF says Millie's treatment for cancer
550469 - ordered by Kaiser will be terminated if UCSF does not
550470 - receive payment of $202.65. ref SDS 57 KM8J
550472 - ..
550473 - UCSF can get assistance collecting payment on improperly denied
550474 - claims by Kaiser...
550476 - Abraham Wax PC
550477 - Attorney at Law
550478 - 750 Third Avenue
550479 - New York, NY 10017
550480 - 212 922 9004
550482 - http://www.abew.com/
550484 - ..
550485 - Assist health care providers collect health care claims
550486 - from insurance companies, ERISA plans, and Medicare.
Kaiser Blood Tests Rejects Payment Medicare Required for Routine Car
850401 - ..
850402 - Kaiser May be Rejecting Medicare Payment for Blood Tests
850403 - Blood Tests Lab Costs Routine Care Trials Kaiser Charges Millie
850405 - Bob indicated today that he got the impression from a telephone call
850406 - with Barbara in Kaiser's Outside Referral Department that Kaiser
850407 - decided to reject payment of charges for blood tests performed at UCSF
850408 - for Millie's treatment in the clinical trial. Bob feels Kaiser wants
850409 - to perform blood tests and send results to UCSF for managing Millie's
850410 - routine care in the clinical trial so that Kaiser benefits from the
850411 - revenue transaction. The UCSF invoice Bob presented today shows a
850412 - great many charges for lab work, ref SDS 0 XQ4O Bob feels this may be
850413 - one reason Kaiser's Medicare unit has been telling UCSF to bill the
850414 - customer for extra expense listed in the spreadsheet Bob submitted
850415 - today showing annual amount of UCSF's claim for $10K, per above.
850416 - ref SDS 0 W05N During the meeting, Bob tried to find a correlation
850417 - between amounts in UCSF claim against Millie and amounts listed in
850418 - UCSF invoices showing specific charges for blood tests and lab work.
850419 - He was unable to show any correlation.
850421 - [...below, Bob asks why blood tests are done at UCSF rather
850422 - than Kaiser. ref SDS 0 T176
850424 - ..
850425 - [On 070917 UCSF letter dated 070912 makes adjustments that may
850426 - eliminate improver charges for laboratory blood test work,
850427 - ref SDS 38 2O9G, but this is not actually stated in the UCSF
850428 - letter. ref SDS 38 595P
850430 - ..
850431 - [On 070917 further review confirms there is no correlation
850432 - between UCSF invoices and claims for recovery from Millie.
850433 - ref SDS 38 WO6X
850435 - ..
850436 - [On 070919 notified Jackie to order blood tests at UCSF to
850437 - start the next cycle of treatment for Millie on 070920.
850438 - ref SDS 39 TZ9Q
850440 - ..
850441 - [On 070927 Kaiser guidance for Senior Advantage calls for no
850442 - coinsurance charges on laboratory work to support clinical
850443 - trials. ref SDS 43 4B4N
850447 - ..
850448 - Account Balance Transfer Charges Not Justified Invoice Confusing
850449 - Invoice Confusing Account Balance Transfer Charges Not Justified
850450 - Chemotherapy Paid by Clinical Trial Double Billed in Invoices
850451 - Invoices No Correlation Medical Services and Charges to Patient
850453 - Bob used UCSF's invoice #12593370 for services on March 1, 2007 to
850454 - illustrate failure to comply with UCSF Patient Bill of Rights for
850455 - clear and complete information, per above, ref SDS 0 WU5N, because
850456 - there is no correlation between UCSF charges for medical services and
850457 - Kaiser's calculation of UCSF's claim for recovery of any amounts
850458 - listed in UCSF invoices and statements submitted to the patient, as
850459 - noted by Bob per above. ref SDS 0 5W5G
850461 - ..
850462 - Invoice 12593370 was initially dated 070410 and showed a total of
850463 - zero, i.e., nothing - $0.00 owed by the patient. This aligned with
850464 - agreement between UCSF and Kaiser to pay for any costs not covered by
850465 - the clinical trial, which holds the patient harmless of all charges
850466 - for treatment prescribed by the doctor, as a duty of care in exchange
850467 - for payment of insurance premiums.
850469 - ..
850470 - UCSF submitted invoice 12593370 again on 070810 and showed the patient
850471 - owed $202.65 but this was not associated with any medical services
850472 - performed by UCSF for the patient.
850474 - ..
850475 - Today, Bob submitted a 3rd revised version of invoice 12593370 now
850476 - dated 070823, and claiming the patient owes $1,240.96 or possibly
850477 - twice that amount, but specifies no evident service for the charges,
850478 - as follows...
850481 - [On 070925 Bob confirmed in telecon there is no correlation
850482 - between charges to the patient and charges for medical services
850483 - listed in UCSF invoices. ref SDS 42 VN5M
850485 - ..
850486 - Hospital Itimized Statement HOSP NO.
850487 - UCSF Medical Center 050454
850488 - Patient Financial Services
850489 - Box 0810
850490 - San Francisco, Ca 94145-0810
850491 - FEI # 94-3281657
850493 - ..
850494 - ACCOUNT ADMISSION DATE OF PAGE 1 OF 2
850495 - NUMBER DATE BILL
850496 - 12593370 03/01/07 08/23/07
850498 - ..
850499 - DATE SERVICE TOTAL BILLED PATIENT
850500 - SVC Q CODE DESCRIPTION CHARGES INSURANCE AMOUNT
850501 - 030107 2 6380278 SOLN 0.9 NACL 250ML INJ 2BY38 18.00 18.00
850502 - 030107 1 3560642 PROTHROMBIN TIME 67.33 67.33
850503 - 030107 1 3560643 PTT, ACTIVATED 95.69 95.69
850504 - 030107 1 3560693 CBC W/AUTO DIFF & PLT CO 85.32 85.32
850505 - 030107 1 3620131 PROTEIN TOTAL SERUM 36.32 36.32
850506 - 030107 1 3620132 ALBUMIN SERUM 49.12 49.12
850507 - 030107 1 3620133 CALCIUM TOTAL 51.16 51.16
850508 - 030107 1 3620140 BILIRUBIN TOTAL 49.44 49.44
850509 - 030107 1 3620337 SODIUM SERUM 47.66 47.66
850510 - 030107 1 3620340 POTASSIUM SERUM 45.62 45.62
850511 - 030107 1 3620500 AST (GOT) 51.28 51.28
850512 - 030107 1 3620501 ALKALINE PHOSPHATASE 51.40 51.40
850513 - 030107 1 3620565 ALT (GPT) 52.49 52.49
850514 - 030107 1 3620900 CA 15-3 TUMOR IMMUNOASSAY 71.70 71.70
850515 - 030107 1 3600903 CHLORIDE SERUM 45.62 45.62
850516 - 030107 1 3620904 CARBON DIOXIDE 48.51 48.51
850517 - 030107 1 3620911 UREA NITROGEN SERUM QNT 39.09 39.09
850518 - 030107 1 3620912 CREATININE SERUM 50.80 50.80
850519 - 030107 1 3620943 MAGNESIUM SERUM 66.48 66.48
850520 - ..
850521 - 030107 1 6382448 CHEMO ADM IV INF UP TO 1 HR 300.00 300.00
850522 - 030107 1 6382800 00071425913 BENADRYL UPTO 50M 3.00 3.00
850523 - 030107 1 6382167 TX/DX/PROPH IV PUSH INIT DRU 135.00 135.00
850524 - 030807 2 6380278 SOLN 0.9 NACL 250ML INJ 2BY38 18.00 18.00
850525 - 030807 1 3560693 CBC W/AUTO DIFF & PLT CO 85.32 85.32
850526 - 030807 1 6382448 CHEMO ADM IV INF UP TO 1 HR 300.00 300.00
850527 - 030807 1 6382800 00071425913 BENADRYL UPTO 50M 3.00 3.00
850528 - 030807 1 6382167 TX/DX/PROPH IV PUSH INIT DRU 135.00 135.00
850529 - 031507 1 6380278 SOLN 0.9 NACL 250ML INJ 2BY38 9.00 9.00
850530 - 031507 1 6380501 NEEDLE HUBER SAF T 20GA X Y38 47.00 47.00
850531 - 031507 1 6382448 CHEMO ADM IV INF UP TO 1 HR 300.00 300.00
850532 - 031507 1 6382032 63323054031 HEPARIN NA/1000 U 11.00 11.00
850533 - 031507 1 6382800 00071425913 BENADRYL UPTO 50M 3.00 3.00
850534 - 031507 1 6382167 TX/DX/PROPH IV PUSH INIT DRU 135.00 135.00
850535 - 032207 1 6380278 SOLN 0.9 NACL 250ML INJ 2BY38 9.00 9.00
850536 - 032207 1 6382448 CHEMO ADM IV INF UP TO 1 HR 300.00 300.00
850537 - 032207 1 6382800 00071425913 BENADRYL UPTO 50M 3.00 3.00
850538 - 032207 1 6382167 TX/DX/PROPH IV PUSH INIT DRU 135.00 135.00
850539 - 032907 2 6380278 SOLN 0.9 NACL 250ML INJ 2BY38 18.00 18.00
850540 - 032907 1 6380501 NEEDLE HUBER SAF T 20GA X Y38 47.00 47.00
850541 - 032907 1 3560642 PROTHROMBIN TIME 67.33 67.33
850542 - 032907 1 3560693 CBC W/AUTO DIFF & PLT CO 85.32 85.32
850543 - 032907 1 3620131 PROTEIN TOTAL SERUM 36.32 36.32
850545 - ..
850546 - PAY THIS AMOUNT.......................................................... $1,240.96
850549 - ..
850550 - ACCOUNT ADMISSION DATE OF PAGE 2 OF 2
850551 - NUMBER DATE BILL
850552 - 12593370 03/01/07 08/23/07
850554 - ..
850555 - DATE SERVICE TOTAL BILLED PATIENT
850556 - SVC Q CODE DESCRIPTION CHARGES INSURANCE AMOUNT
850557 - 032907 1 3620132 ALBUMIN SERUM 49.12 36.32
850558 - 032907 1 3620133 CALCIUM TOTAL 51.16 36.32
850559 - 032907 1 3620140 BILIRUBIN TOTAL 49.44 36.32
850560 - 032907 1 3620337 SODIUM SERUM 47.66 36.32
850561 - 032907 1 3620340 POTASSIUM SERUM 45.62 36.32
850562 - 032907 1 3620500 AST (GOT) 51.28 36.32
850563 - 032907 1 3620501 ALKALINE PHOSPHATASE 51.40 36.32
850564 - 032907 1 3620565 ALT (GPT) 52.49 36.32
850565 - 032907 1 3620900 CA 15-3 TUMOR IMMUNOASSAY 71.70 36.32
850566 - 032907 1 3600903 CHLORIDE SERUM 45.62 36.32
850567 - 032907 1 3620904 CARBON DIOXIDE 48.51 36.32
850568 - 032907 1 3620911 UREA NITROGEN SERUM QNT 39.09 36.32
850569 - 032907 1 3620912 CREATININE SERUM 50.80 36.32
850570 - 032907 1 3620943 MAGNESIUM SERUM 66.48 36.32
850571 - ..
850572 - 032907 1 6382448 CHEMO ADM IV INF UP TO 1 HR 300.00 36.32
850573 - 032907 1 6382963 COLLECT BLOOD VENOUS DEV 171.00 36.32
850574 - 032907 1 6382032 63323054031 HEPARIN NA/1000 U 11.00 11.00
850575 - 032907 1 6382800 00071425913 BENADRYL UPTO 50M 3.00 3.00
850576 - 032907 1 6382167 TX/DX/PROPH IV PUSH INIT DRU 135.00 135.00
850577 - 060407 1 0501080 MORE INFO NEEDED FOR ADJUCIC 0.00 0.00
850578 - 060407 1 0017010 OTHER MDG CARE MCARE PYMT 0.00 0.00
850579 - 060407 1 0011055 NEIC ERA ZERO PYMT 0.00 0.00
850580 - ..
850581 - 060407 1 0101005 DENIED CO-INSURANCE 202.65 202.65 202.65
850582 - 060407 1 0010610 M-CARE OP PYMT 1776.54- 1776.54-
850583 - 060407 1 0101005 DENIED CO-INSURANCE 202.65- 202.65-
850584 - 060407 1 0300610 M-CARE OP CONTRACT ADJ 1531.99- 1531.99-
850585 - ..
850586 - 060407 1 0100005 ACCOUNT BALANCE TRANSFER 1038.31 1038.31
850587 - 060407 1 0100005 ACCOUNT BALANCE TRANSFER 1038.31- 1038.31-
850589 - ..
850590 - BALANCE FORWARD 0.00
850592 - ..
850593 - SUMMARY OF CURRENT PAYMENTS/ADJUSTMENTS 3038.53- 4549.49-
850595 - ..
850596 - SUMMARY OF CURRENT CHARGES
850598 - PHARMACY 109.00 109.00
850599 - SUPPLY/DEVICES 94.00 94.00
850600 - LAB 2000.49 2000.49
850601 - RADIOLOGY/THER 1500.00 1500.00
850602 - OTHER 675.00 675.00
850604 - ..
850605 - PAY THIS AMOUNT.......................................................... $1,240.96
850607 - ..
850608 - There is correlation between the amount UCSF billed in the invoice of
850609 - $4,549.49 and the amount on Bob's spreadsheet summary, but there is
850610 - nothing showing support for Patient Charges of $1,240.96. As seen
850611 - above, if the patient paid UCSF invoices, this would require two (2)
850612 - payments of $1,240.96, totalling $2,481 92, which evidently is
850613 - incorrect, since the UCSF statement received weeks later shows only
850614 - one payment is actually owed of $1,240.96 for account 12593370, per
850615 - above. ref SDS 0 WP5I
850617 - ..
850618 - [On 070917 UCSF revised spreadsheet shows invoice 12593370 has
850619 - been revised a 4th time charging $202.65 for coinsurance.
850620 - ref SDS 38 MK4H
850622 - ..
850623 - [On 070917 UCSF request for interim payment of conisurnace on
850624 - doctor visits charged at $101.00 example of no correlation
850625 - between charges and services performed by UCSF. ref SDS 38 WO6X
850627 - ..
850628 - [On 070917 review shows coinsurance is aimed at supporting
850629 - supplemental/secondary insurance in the private sector that
850630 - provides Medigap coverage of coinsurance. ref SDS 38 TN3O
850632 - ..
850633 - [On 070917 Kaiser tells new members to cancel Medigap insurance
850634 - coverage, because Kaiser Senior Advantage performs this scope.
850635 - ref SDS 38 EZ56
850637 - ..
850638 - [On 070924 UCSF notified invoices and billing procedures too
850639 - complex; impossible for patients to make payments. ref SDS 41
850640 - UL6X
850642 - ..
850643 - [On 071031 Millie receives notice dated 071026 UCSF has
850644 - scheduled assignment to a collection agency for payment of
850645 - account 12493370 in the amount of $202.65, ref SDS 57 KK4I,
850646 - reviewed on 070830, ref SDS 33 4P8K, and revised again on
850647 - 070917, ref SDS 38 MK4H; there is no indication of UCSF
850648 - collection efforts against Kaiser who ordered the work; and
850649 - in a separate notice the next day on 071027 UCSF threatens
850650 - that Millie's treatment for cancer ordered on referral by
850651 - Kaiser will be terminated if UCSF does not receive payment
850652 - from Millie, which is owed by Kaiser. ref SDS 57 KM8J
850654 - ..
850655 - [On 071128 Kaiser Appeals Committee approved payment for
850656 - Millie's care on referral to UCSF. ref SDS 58 JZ5R
850658 - ..
850659 - Bob initially pointed to page 2 to support his understanding from
850660 - discussions with Barbara in Kaiser's Outside Referral Department that
850661 - Kaiser wants the patient to pay for blood tests. He noted there is an
850662 - amount of $202.65 for "denied co-insurance," ref SDS 0 WO8I, which
850663 - cannot be reconciled against any primary insurance base amount,
850664 - discussed further below, ref SDS 0 W06L, and there is another amount
850665 - of $1038.31 for "Account balance transfer." ref SDS 0 WO8M He
850666 - indicated this charge was for blood tests, but he then decided that
850667 - the amount for "LAB" of "$2,000.49" conflicts with this understanding.
850668 - ref SDS 0 MF92
850670 - [On 070831 letter to UCSF confirms understandings today that
850671 - there is no correlation between UCSF billings to the patient
850672 - and any charges for lab blood tests. ref SDS 34 PZ4S
850674 - ..
850675 - [On 070925 Bob confirmed in telecon there is no correlation
850676 - between charges to the patient and charges for medical services
850677 - listed in UCSF invoices. ref SDS 42 VN5M
850679 - ..
850680 - [On 070927 Kaiser guidance for Senior Advantage calls for no
850681 - coinsurance charges on laboratory work to support clinical
850682 - trials. ref SDS 43 1F67
850684 - ..
850685 - There is no explanation of "Account balance transfer" charges in
850686 - relation to any medical service UCSF has performed. During the
850687 - meeting today, Bob was not aware of how this amount is calculated or
850688 - otherwise determined. ref SDS 0 WO8M
850690 - ..
850691 - Charges for chemotherapy, ref SDS 0 F94O, and related services in UCSF
850692 - invoices shown by the examples above, ref SDS 0 WN9N, may conflict
850693 - with planning on 061230 by Kaiser and UCSF for the clinical trial to
850694 - pay for chemotherapy scope. UCSF indicated at that time that the only
850695 - charges not funded by the trial are for "standard of care."
850696 - ref SDS 15 3X6K
850698 - ..
850699 - [...below, patient concerns about level of effort to review,
850700 - understand, and approve invoices for payment. ref SDS 0 RV6F
850702 - ..
850703 - [On 070917 UCSF submitted revised spreadsheet eliminating all
850704 - extra charges except for coinsurance for which recovery is
850705 - claimed in the amount of $1,506.60. ref SDS 38 J14R
850707 - ..
850708 - [On 070924 letter to UCSF asks why invoices bill for
850709 - chemotherapy charges funded by the trial? ref SDS 41 UM3V
850711 - ..
850712 - Bob asked why CT tests are done at Kaiser and not blood tests?
850714 - ..
850715 - CT tests require correlations with prior test history to assess trends
850716 - that guide diagnosis and treatment decisions, shown by Millie's
850717 - patient history listed on 060523, ref SDS 12 4O60 Analysis of image
850718 - tests is performed by professionals who prepare extensive written
850719 - reports explaining findings from complex scan images, and comparisons
850720 - with previous tests indicating rates of change that guide treatment
850721 - decisions. Results of image testing are valid for weeks and even
850722 - months in the case of cancer patients. Since Kaiser has a long
850723 - history of past CT tests on file, this body of work can be easily
850724 - reviewed to make comparisons required for effective analysis. Lead
850725 - time of several days to a week or more for image testing further
850726 - supports testing through Kaiser, and submitting results to UCSF for
850727 - compliance with clinical trial protocol requirements reported on
850728 - 070116. ref SDS 19 SE8M
850730 - [On 070831 letter to UCSF explains image (CT) testing practical
850731 - performed at Kaiser and submitted to UCSF. ref SDS 34 PZ4X
850735 - ..
850736 - Lab Blood Tests Essential for Realtime Monitor Chemotherapy Care
850738 - Blood tests provide crucial data on immediate patient condition to be
850739 - safely treated with chemotherapy. If lab tests done a day or so prior
850740 - to treatment are negative, retesting may be ordered to see if blood
850741 - counts show sufficient improvement for same day treatment, or have to
850742 - be deferred for a day or a week and medication prescribed, e.g.,
850743 - Neupogen, procrit, etc., to increase blood counts sufficiently for
850744 - safe chemotherapy treatment, shown by case study on patient history
850745 - reported 060810. ref SDS 13 HV45 Kaiser and UCSF initially tried
850746 - doing blood tests at Kaiser. This caused errors and duplication that
850747 - increased costs for Kaiser and risks to the patient, illustrated by
850748 - the record on 070130 showing Millie had numerous blood tests at Kaiser
850749 - that had to be done over, ref SDS 21 MP4H, cited in the case study on
850750 - difficulties of complex coordination between Kaiser and UCSF reported
850751 - also on 070130. ref SDS 22 2X6L Additionally, if the patient
850752 - experiences duress during treatment, blood tests may be required to
850753 - assess whether a patient can be released to go home, or needs
850754 - emergency treatment, as occurred at Kaiser on 070607. ref SDS 29 8J37
850756 - [On 070927 Kaiser guidance for Senior Advantage calls for no
850757 - coinsurance charges on laboratory work to support clinical
850758 - trials. ref SDS 43 4B4N
850760 - ..
850761 - [On 090213 Kaiser Oncology explains doctors must rely on local
850762 - labs for cost effective care, because local computers assemble
850763 - trends quickly and accurately, and familiarity with variances
850764 - prevents mistakes caused by using data from other labs with
850765 - different units of measure, and daily work is hectic.
850766 - ref SDS 63 4Y8F
850768 - ..
850769 - Immediacy of medical decisions make blood tests an integral part of
850770 - routine care for cancer patients, discussed the first day of treatment
850771 - on 070201. ref SDS 23 XR40 Blood tests comprise hundreds of figures
850772 - and multiple units of measure. Scope and units of measure vary
850773 - significantly between Kaiser and UCSF, reported on 070301. ref SDS 27
850774 - HI6O These variances compound complex communications ordering blood
850775 - testing at Kaiser for use at UCSF. Millie's primary care physician at
850776 - Kaiser reported on 070517 that CA 15-3 blood tests at Kaiser and UCSF
850777 - is comparing apples and oranges. ref SDS 26 NT3O Doctor Rugo's Nurse
850778 - Practitioner, Brigid, advised in a letter on 070517 that blood testing
850779 - should be done at UCSF to avoid confusing lab standards. ref SDS 28
850780 - 466H
850782 - [On 090213 example of CA 15-3 at UCSF 113 relatively stable over 3
850783 - weeks, while at Kaiser CA 15-3 303 jumped 100 points in a few
850784 - weeks, ref SDS 63 A46O; as a result, effective care requires blood
850785 - tests at local facility, rather than rely on cross-hospital data.
850786 - ref SDS 63 4Y8F
850788 - ..
850789 - Delays resolving confusion from complexity increase risks of error
850790 - exponentially, shown by efforts to get blood test reports done at
850791 - Kaiser and sent to UCSF on 070119. ref SDS 20 AS6M Busy practitioners
850792 - experienced making critical decisions by quickly glancing through a
850793 - maze of familiar figures, place the patient at extreme risk of error
850794 - by mixing test reports with different units and standards, even though
850795 - with plenty of time valuations can be converted to local standards,
850796 - also noted on 070301. ref SDS 27 R14I
850798 - [On 070831 letter to UCSF explains blood tests comprise routine
850799 - care treating cancer patients that require local control, and so
850800 - are no practicle to be performed at Kaiser and submitted to UCSF.
850801 - ref SDS 34 PZ4X
850803 - ..
850804 - [On 070917 UCSF letter dated 070912 makes adjustments that may
850805 - eliminate improver charges for laboratory blood test work,
850806 - ref SDS 38 2O9G, but this is not actually stated in the UCSF
850807 - letter. ref SDS 38 595P
850809 - ..
850810 - [On 071015 charges for blood tests continue to appear on UCSF
850811 - invoices for clinical trial referral work; Millie asks UCSF to
850812 - order blood tests at Kaiser in order to evaluate if this change
850813 - will resolve payment dispute. ref SDS 48 KH5T
850815 - ..
850816 - [On 071017 problems ordering blood tests at Kaiser the day before
850817 - treatment at UCSF - Jackie faxes request for blood draw to Arlette
850818 - at Kaiser in Walnut Creek, Millie's main treatment location.
850819 - ref SDS 49 Q45F Arlette is at lunch, delay finding out where to
850820 - get blood drawn. ref SDS 49 4Q5M Arlette advises UCSF blood draw
850821 - request was ordered by the doctor; tells customer to coordinate
850822 - with Kaiser to schedule blood draws. ref SDS 49 4Q7G Kaiser in
850823 - Walnut Creek cannot do blood draw until next week, ref SDS 49
850824 - YE9G; Millie goes to Kaiser in Martinez for the blood draw; finds
850825 - the order is not entered in the computer, ref SDS 49 OS3F; blood
850826 - draw performed using order found in the computer for prior blood
850827 - draw from last January. ref SDS 49 OS5K
850829 - ..
850830 - [On 071018 blood test results were not available for review during
850831 - examination, ref SDS 50 HL7O, treatment at UCSF was delayed for an
850832 - hour or so until Kaiser submitted blood test results via fax.
850833 - ref SDS 50 6N9F
850835 - ..
850836 - [On 071019 UCSF clinical trial staff confuses Neutrophils in
850837 - Kaiser's blood test report on 071017, for NEUTS used by UCSF to
850838 - assess patient safety for treatment. ref SDS 52 EU5U
850840 - ..
850841 - [On 071024 letter to UCSF proposes returning to performing blood
850842 - tests at UCSF in order to avoid problems of confusion and delay,
850843 - provided UCSF demonstrates there are no extra charges in billings.
850844 - ref SDS 53 EP5W
Claim $10K UCSF Against Patient for Self-referral Medicare Coinsuran
B10401 - ..
B10402 - Clinical Trial Referrals Expand Treatments Integral Oncology Practice
B10403 - $10K Claim Treatment Clinical Trial Conflicts with Patient History
B10404 - Double Dipping Savings Not Justified Kaiser Responsible Cost Standard of Care
B10406 - Bob commented that the only reason Millie is a target for a claim to
B10407 - recover "patient responsibility" payment of approximately $40K per
B10408 - year, per above, ref SDS 0 W05N, over and above insurance payments to
B10409 - Kaiser and Medicare is because clinical trial work is being performed
B10410 - at UCSF and Kaiser has directed UCSF to bill Medicare and the patient
B10411 - rather than Kaiser. He seemed to say that if the same treatment were
B10412 - given at Kaiser, Millie would not be subject to such claims.
B10414 - [On 071006 Millie received additional billings from UCSF that
B10415 - indicate total charges would be in the range of $15K - $20K per
B10416 - year. ref SDS 45 PRWW
B10418 - ..
B10419 - Bob indicated Kaiser has informed UCSF that, since Medicare offers a
B10420 - benefit that patients can self-refer without authorization from the
B10421 - doctor to participate in clincial trials that advance medical science
B10422 - to develop treatments that may help future patients, Kaiser is thereby
B10423 - shielded from performing its duty of care for current patients by
B10424 - avoiding payment of treatment Kaiser prescribes; and, so in this case,
B10425 - Kaiser directs UCSF to bill Medicare for primary insurance coverage,
B10426 - and bill Millie for coinsurance, rather than bill Kaiser for costs of
B10427 - standard of care, which Kaiser had agreed to pay in the letter to UCSF
B10428 - on 061230. ref SDS 15 3X6K
B10430 - [...analysis Kaiser "self-referral" theory fails test of common
B10431 - scenarios. ref SDS 0 T259
B10433 - ..
B10434 - Kaiser seeks to transfer responsibility for 100% of costs for standard
B10435 - of care to Millie and to Medicare simply by prescribing treatment at
B10436 - UCSF on 070105, ref SDS 17 PK7L, and now 8 months later cloaking
B10437 - referral for needed treatment of oncology services in the guise of
B10438 - patient "self-referral" to advance medical science. Kaiser benefits
B10439 - from reducing its cost of care by contract referral for treatment at
B10440 - UCSF that pays for chemotherapy drugs through a clinical trial, noted
B10441 - by Doctor Rugo in UCSF correspondence with Kaiser received on 061230.
B10442 - ref SDS 15 3X6K There are no grounds for Kaiser to "double dip" on
B10443 - cost savings at the patients expense by failure to perform
B10444 - requirements to pay any costs for standard of care, as Kaiser agreed
B10445 - to perform on 061230. ref SDS 15 3X6K
B10447 - [On 070921 Kaiser saves a lot of money having UCSF treat Millie
B10448 - in clincial trial that pays for cetuximab and carboplatin
B10449 - drugs. ref SDS 40 QY58
B10451 - ..
B10452 - [On 070924 letter to UCSF proposes compromise to avoid Kaiser
B10453 - double dipping transferring costs of care to the patient that
B10454 - are covered by insurance payments. ref SDS 41 UL9X
B10456 - ..
B10457 - [On 070927 Kaiser Senior Advantage EOC section 7 describes
B10458 - coinsurance for patients who "self-refer" to clinical trials
B10459 - for advancing medical research, ref SDS 43 1G4O, which does not
B10460 - apply for Millie's treatment at UCSF prescribed by Kaiser for
B10461 - essential care, ref SDS 43 1F92, also explained on 070917,
B10462 - ref SDS 38 596Q; Kaiser EOC section 2 says the doctor must
B10463 - prescribe treatment needed for covered services, which includes
B10464 - oncology care. ref SDS 43 WS6M
B10466 - ..
B10467 - [On 070927 Kaiser's failure to perform medical requirements of
B10468 - EOC raise 16 issues involving patient health, Medicare law and
B10469 - regulation, CMS contract management, Kaiser medical practice,
B10470 - ethics, and standards for oncology care, and billing
B10471 - procedures. ref SDS 43 WU6M
B10473 - ..
B10474 - [On 071128 Kaiser Appeals Committee approved payment for
B10475 - Millie's care on referral to UCSF. ref SDS 58 JZ5R
B10479 - ..
B10480 - Clinical Trials Prescribed by Kaiser Routinely Charge No Coinsurance
B10481 - Self-referral Not Supported by Patient History; Kaiser Prescribes
B10482 - Case Study Kaiser Routinely Prescribed Treatment Clinical Trials
B10483 - Referrals Kaiser Routinely Coordinates Pays All Costs Patient Never Sees Invoice
B10485 - Kaiser has routinely made many referrals prescribing treatment for
B10486 - medical necessity in this case as part of oncology practice, and has
B10487 - never previously demanded additional payment of any kind, including
B10488 - clinical trial coinsurance.
B10490 - ..
B10491 - [On 070927 Kaiser Senior Advantage EOC section 2 says the
B10492 - doctor must prescribe treatment needed for covered services,
B10493 - which includes oncology care. ref SDS 43 WS6M
B10495 - ..
B10496 - For six (6) years, Millie never received even one invoice for extra
B10497 - charges of "coinsurance" on clinical trial treatment integral to
B10498 - oncology practice, contrary to experience at UCSF where she has about
B10499 - 60 documents and counting, illustrated by the one above, ref SDS 0
B10500 - 4P8K, demanding annualized payment of about $10K, ref SDS 0 W05N, for
B10501 - unspecified charges...
B10503 - 1. Clinical trial referrals part of
B10504 - Kaiser oncology
B10505 - practice.............................. 020321, ref SDS 2 O49J
B10507 - ..
B10508 - 2. Referral cancer treatment to Mt Diablo
B10509 - Hospital prescribed by primary care
B10510 - physician Kaiser made all arrangements
B10511 - coordinated schedule, managed the work,
B10512 - paid all costs, patient never saw
B10513 - an invoice............................ 020628, ref SDS 3 QB5Q
B10515 - ..
B10516 - 3. Doctor reports biopsy indicates Millie
B10517 - must start treatment for cancer relapse;
B10518 - doctor has made arrangements for
B10519 - referral to a clinical trial
B10520 - as the best course of
B10521 - treatment............................. 040306, ref SDS 4 WG7F
B10523 - ..
B10524 - 4. Metastatic cancer diagnosed relapse
B10525 - biopsy lymph nodes supraclavicular
B10526 - region requires immediate
B10527 - treatment............................. 040318, ref SDS 5 8R6M
B10529 - ..
B10530 - 5. Referral cancer treatment clinical
B10531 - trial bevacizumab (Avastin) and Taxol
B10532 - prescribed by primary care physician;
B10533 - Kaiser made all arrangements coordinated
B10534 - schedule, managed the work, paid all
B10535 - costs, patient never saw an
B10536 - invoice............................... 040318, ref SDS 5 PU6M
B10538 - ..
B10539 - 6. Clinical trials part of "tool kit"
B10540 - for oncology services expand doctor's
B10541 - treatments that extend and
B10542 - improve quality of
B10543 - life.................................. 040318, ref SDS 5 DG4J
B10545 - ..
B10546 - 7. Patient resisted referral to clinical
B10547 - trial that delayed treatment of IBC
B10548 - relapse with established chemotherapy
B10549 - drugs after Kaiser ended treatment with
B10550 - bevacizumab Taxol that caused pulmonary
B10551 - embolism; Kaiser insisted on prescribing
B10552 - treatment with clinical trial, even
B10553 - though nothing was available at the
B10554 - time, and initiated search for
B10555 - clinical trial........................ 041130, ref SDS 6 028N
B10557 - ..
B10558 - 8. Kaiser prescribes treatment with Novel
B10559 - Epothilones BMS-247550 and capecitabine
B10560 - delivered through clinical trial;
B10561 - schedules expedited chemotherapy to
B10562 - prevent cancer from cascading
B10563 - out of control........................ 041210, ref SDS 7 028N
B10565 - ..
B10566 - 9. Meeting with director of clinical trials
B10567 - on arrangements for starting treatment
B10568 - does not discuss extra charges,
B10569 - self-referral, nor coinsurance;
B10570 - Millie requests expedited
B10571 - treatment............................. 041210, ref SDS 7 4R5J
B10573 - ..
B10574 - 10. Director of clinical trials cancels
B10575 - Millie starting treatment in 2 days,
B10576 - because Kaiser discovered patient had
B10577 - only 2 treatments with AC for adjuvant
B10578 - chemotherapy in 2002; the clinical trial
B10579 - protocol required 4 treatments; rather
B10580 - than treat with established drugs Taxol
B10581 - or Taxotere that were proven effective
B10582 - in patient history, Kaiser delayed
B10583 - treatment from 041020 to
B10584 - discuss referral to
B10585 - clinical trial........................ 041221, ref SDS 8 0001
B10587 - ..
B10588 - 11. Patient asked about starting treatment
B10589 - with established drugs, Taxol or
B10590 - Taxotere.............................. 041230, ref SDS 9 2V85
B10592 - ..
B10593 - 12. Kaiser prescribed treatment with AC
B10594 - which had been stopped in 2002 due to
B10595 - progression of disease, but seemed
B10596 - required in 2004 to qualify Millie
B10597 - for referral to clinical trial
B10598 - treatment............................. 041230, ref SDS 9 XQ41
B10600 - ..
B10601 - 13. Cancer - IBC - expands beyond the
B10602 - breast during 3 months from October
B10603 - to January............................ 050107, ref SDS 10 6W6O
B10604 - while Kaiser searched for clinical
B10605 - trials to prescribe treatment;
B10606 - surgeon advises opportunity for
B10607 - mastectomy to remove infected skin
B10608 - no longer possible because there
B10609 - is now no evident boundary
B10610 - of disease to
B10611 - remove................................ 050107, ref SDS 10 UM6I
B10613 - ..
B10614 - 14. IBC worsening under treatment with AC;
B10615 - doctor learns Millie cannot qualify
B10616 - for referral to clinical drug trial
B10617 - after 2 more treatments with AC,
B10618 - because protocol requires 4
B10619 - consecutive treatments
B10620 - with AC............................... 050204, ref SDS 11 028N
B10622 - ..
B10623 - 15. Case study Kaiser has relied on clinical
B10624 - trial referals for prescribing
B10625 - essential oncology
B10626 - practice.............................. 061208, ref SDS 14 WI3J
B10628 - ..
B10629 - 16. Cetuximab Carboplatin clinical trial Kaiser
B10630 - prescribes treatment; schedules expedited
B10631 - chemotherapy to prevent cancer
B10632 - from cascading out of
B10633 - control............................... 070105, ref SDS 17 PK7L
B10635 - ..
B10636 - 17. Case study shows Kaiser prescribed treatment
B10637 - with cetuximab and carboplatin clinical
B10638 - trial at UCSF paid entirely by Kaiser
B10639 - to carry out Kaiser's obligation
B10640 - for providing the best course of
B10641 - care for Millie's patient
B10642 - profile.............................. 070130, ref SDS 22 2X6L
B10644 - ..
B10645 - 18. Sunitinib clinical trial prescribed by
B10646 - Doctor Rugo and ordered by Doctor Johnson
B10647 - on referral from Kaiser, shown
B10648 - in work plan......................... 081029, ref SDS 61 LH4O
B10649 - Kaiser refuses payment refers
B10650 - everyone to Medicare................. 081110, ref SDS 62 YH8I
B10651 - Kaiser paid all costs of medical
B10652 - services at UCSF as the best course
B10653 - of treatment for Millie to recover
B10654 - from 6th relapse of
B10655 - cancer............................... 090601, ref SDS 65 N54G
B10659 - ..
B10660 - Insurance Senior Advantage Since 2002 Why Extra Charges in 2007??
B10662 - Millie was 65 in 2002, and so had the same insurance coverage she has
B10663 - today, paying premiums directly to Kaiser, and by law indirectly to
B10664 - Medicare through reduction in monthly social security payments. At
B10665 - this time, Kaiser has a duty to treat Millie's precondition of cancer,
B10666 - starting in 2002. Since Kaiser made referral on 061230, based on
B10667 - agreement to pay all costs not paid by the clinical trial, ref SDS 15
B10668 - 3X6K, and since Kaiser directed Millie on 070105 to get treatment at
B10669 - UCSF and did not disclose extra charges of any kind, ref SDS 17 P256,
B10670 - then in agreeing to accept Kaiser's referral to UCSF, Millie
B10671 - reasonably expected comparable experience that all costs of treatment
B10672 - would be paid by her insurance premiums and established co-payments,
B10673 - as with many previous treatments prescribed by Kaiser for clinical
B10674 - trial referrals shown in case study of patient history above.
B10675 - ref SDS 0 LQ5I All other costs are the responsibility of Kaiser, as
B10676 - noted in Kaiser's letter to UCSF submitted on 061230 by the primary
B10677 - care physician. ref SDS 15 3X6K
B10679 - ..
B10680 - How Kaiser chooses to pay UCSF for the referral ordered by her doctor
B10681 - at Kaiser is of no concern to Millie, just as it was of no concern
B10682 - during prior trials in 2004, nor prior referral to Mt Diablo in 2002.
B10683 - As shown on 020628, then as now, Kaiser made no disclosure of annual
B10684 - extra charges for coinsurance, ref SDS 3 QB5Q, as UCSF now seeks to
B10685 - collect from Millie in the amount of $10K, shown above, ref SDS 0
B10686 - W05N, for treatment ordered by her doctor at Kaiser. Neither for
B10687 - referral to Mt Diablo in 2002, nor for clinical trial treatment in
B10688 - 2004 Millie never received invoices for extra charges above her
B10689 - monthly insurance premium paid to Kaiser (see case study above,
B10690 - ref SDS 0 JW8G), as being demanded by invoices received from Kaiser
B10691 - and UCSF in this case.
B10693 - ..
B10694 - Since Millie's insurance in 2007 is identical to 2002 and 2004, when
B10695 - Kaiser prescribed treatment by referral in clinical trials, and paid
B10696 - for those services with no additional charges of "coinsurance" beyond
B10697 - Millie's insurance payments and established copayments ($30 for doctor
B10698 - visits, $20 for blood tests) there is no reason Kaiser cannot make
B10699 - similar arrangements for equitable payment to UCSF for services
B10700 - ordered by Kaiser to treat Millie in a clinical trial at this time.
B10702 - ..
B10703 - Bob said that Kaiser has notified UCSF to bill charges for Millie's
B10704 - treatment in the clinical trial at UCSF to Kaiser's Medicare unit, and
B10705 - to bill Millie directly for conisurance, which calculates to a rate of
B10706 - 56%, per above, ref SDS 0 WP5I, because Millie can "self-refer" under
B10707 - Medicare law.
B10709 - ..
B10710 - [On 070906 Kaiser policy describes coinsurance applies when
B10711 - patients "self-refer" to participate in a clinical trial.
B10712 - ref SDS 37 WC6S
B10714 - ..
B10715 - [On 070917 received UCSF explanation that coinsurance for
B10716 - clinical trials specified in CMS section 69.9; provides no
B10717 - guidance calculating amounts and patient responsibilities.
B10718 - ref SDS 38 596Q
B10720 - ..
B10721 - [On 070917 research of Title 42 part 419.40 indicates 20%
B10722 - minimum rate of coinsurance for payment on various types
B10723 - (APC groups) of medical services are determined annually by
B10724 - Medicare which suggests these amounts are known in advance
B10725 - of entering treatment agreements. ref SDS 38 4Q3I Service
B10726 - providers can advertise to compete for business offering
B10727 - reduced coinsurance rates. ref SDS 38 6G5H
B10729 - ..
B10730 - [On 070927 Millie found documentation from Kaiser for the
B10731 - Senior Advantage Evidence of Coverage (EOC) Section 7
B10732 - describes coinsurance for "self-referral" to participate in
B10733 - clinical trials for medical research, ref SDS 43 1G4O,
B10734 - which does not apply to services for Millie's treatment at
B10735 - UCSF prescribed by Kaiser for routine care, ref SDS 43
B10736 - 1F92, also explained on 070917. ref SDS 38 596Q
B10738 - ..
B10739 - [On 070927 Kaiser Senior Advantage EOC section 2 presents
B10740 - legal duty for Kaiser to pay for care which the doctor must
B10741 - prescribe to provide needed treatment for covered services
B10742 - like chemotherapy commonly prescribed for oncology
B10743 - services. ref SDS 43 WS6M
B10745 - ..
B10746 - [On 070927 Kaiser's failure to perform legal duty to pay
B10747 - for needed oncology services covered by Senior Advantage
B10748 - EOC presents 16 policy issues for determination by Kaiser,
B10749 - CMS, Medicare, and perhaps the court. ref SDS 43 WU6M
B10751 - ..
B10752 - [On 071128 Kaiser Appeals Committee approved payment for
B10753 - Millie's care on referral to UCSF. ref SDS 58 JZ5R
B10756 - ..
B10757 - Documentation at UCSF Shows Kaiser Referred Millie for Treatment
B10759 - Case study on 070130 shows Millie did not self-refer; Kaiser
B10760 - prescribed treatment to discharge responsibility for patient care,
B10761 - ref SDS 22 2X6L, in the same manner Kaiser has prescribed clinical
B10762 - trials throughout case management beginning in 2002, and paid all
B10763 - costs, per case study above. ref SDS 0 LQ5I
B10765 - ..
B10766 - UCSF has documentation on file from Kaiser showing that Millie did not
B10767 - self-refer, but rather Kaiser prescribed treatment at UCSF as the best
B10768 - course of care for Millie. Arrangements by Millie's doctor at Kaiser
B10769 - were made with Doctor Rugo at UCSF...
B10771 - Primary care physician at Kaiser
B10772 - explains in a letter to Doctor Rugo
B10773 - at UCSF medical necessity for
B10774 - Millie's treatment; discusses
B10775 - qualifying her for clinical
B10776 - trial protocol.................... 061230, ref SDS 15 PO3Q
B10778 - ..
B10779 - Kaiser agrees to pay all costs
B10780 - not paid by the clinical
B10781 - trial............................. 061230, ref SDS 15 3X6K
B10783 - ..
B10784 - UCSF receives patient history
B10785 - from Kaiser to qualify Millie for
B10786 - treatment in clinical
B10787 - trial............................. 070101, ref SDS 16 E23P
B10789 - ..
B10790 - Millie was referred by her doctor to perform Kaiser's duty to provide
B10791 - professional care of an ongoing condition beginning in 2002, as noted
B10792 - by the doctor on 070105. ref SDS 17 PK7L On 070119 Millie's doctor
B10793 - confirmed that he submitted authorization for referral. ref SDS 20
B10794 - 4R4M Now eight (8) months after the fact, Kaiser and UCSF are
B10795 - penalizing a desperate cancer patient at the 11th hour, with fancy
B10796 - financial engineering that has no support in the record of patient
B10797 - history, nor in terms and conditions of Millie's agreement with
B10798 - Kaiser.
B10801 - ..
B10802 - Kaiser's Self-referral Theory Conflicts Patient History
B10803 - Patient Benefits Do Not Shield Kaiser from Paying for Prescribed Care
B10805 - Under Kaiser's "self-referral" theory, the doctor could have referred
B10806 - the patient to UCSF for treatment in 2004, and Millie could have
B10807 - refused and "self-referred" to Kaiser for treatment with bevacizumab
B10808 - (Avastin) and Taxol. Circumstances were all identical. Since in
B10809 - fact, Kaiser made the referral for Millie to get treatment with the
B10810 - bevacizumab and Taxol clinical trial, as shown in the study above,
B10811 - ref SDS 0 LQ5I, and because, as the doctor explained on 040318, such
B10812 - treatment was the best course of professional care to perform Kaiser's
B10813 - duty to provide effective treatment for oncology services, ref SDS 5
B10814 - PU6M, Millie never received billings for extra charges. Equally,
B10815 - since in fact Kaiser made the referral in 2007 to UCSF, Millie has no
B10816 - obligation to pay more than her insurance premiums to Kaiser.
B10818 - [On 071128 Kaiser Appeals Committee approved payment for
B10819 - Millie's care on referral to UCSF. ref SDS 58 JZ5R
B10821 - ..
B10822 - Bob was not aware that UCSF and Kaiser agreed in a letter on 061230
B10823 - that Kaiser would pay for any costs of referral for Millie's treatment
B10824 - at UCSF not paid by the clinical trial. Bob asked to see
B10825 - correspondence documenting agreement for Kaiser to pay for Millie's
B10826 - referral to UCSF. Opened computer c15, and showed Bob the record on
B10827 - 061230, ref SDS 15 3X6K, which cites the letter from the primary care
B10828 - physician at Kaiser to Millie on that date. ref DRP 6 TQ7H
B10830 - [On 071009 USACE representative claims to have received
B10831 - notice from unnamed people at Kaiser that the patient was
B10832 - told the patient would be responsible for coinsurance in
B10833 - Kaiser's transaction arranging for treatment on referral at
B10834 - UCSF. ref SDS 46 N88P
B10836 - ..
B10837 - Bob asked if Doctor Rugo has assigned someone to coordinate UCSF work
B10838 - on Millie's referral from Kaiser? Background on UCSF coordination
B10839 - support is reported on 070116, ref SDS 19 NK8F The coordinator
B10840 - recently advised that Doctor Rugo manages financial issues directly.
B10841 - On 070119 UCSF reported Doctor Rugo investigated payment arrangements
B10842 - prior to UCSF agreeing to treat Millie, ref SDS 20 AS96, following up
B10843 - prior work on 061230, per above. ref SDS 0 T14K
B10845 - ..
B10846 - Discussed today UCSF requesting a meeting with Kaiser to review
B10847 - referral coordination issues and planning. This was presented by the
B10848 - Clinical Trial Coordinator during a meeting at UCSF on 070222 on
B10849 - requirements for a referral plan. As shown in the record at that
B10850 - time, this action item is still pending. ref SDS 24 VK5N Case study
B10851 - on 070130 demonstrates problems that require coordinated solutions
B10852 - between Kaiser and UCSF. ref SDS 22 2X6L On 070228 Millie requested a
B10853 - draft coordination plan for review in advance of meeting with the
B10854 - doctor. ref SDS 25 LQ6R Understandably, hectec schedules at UCSF and
B10855 - Kaiser illustrated by the history of failure to follow up on
B10856 - coordination planning has left UCSF in the lurch with a lot of unpaid
B10857 - charges. ref SDS 24 626J
B10859 - [On 070831 letter to UCSF confirms objective to meet with Kaiser
B10860 - for developing a referral coordination plan. ref SDS 34 PZ4P
B10862 - ..
B10863 - [On 071027 letter to UCSF reminds about need for referral
B10864 - coordination meeting to discuss procedures, terms, and conditions
B10865 - of the work. ref SDS 55 MA8P
B10867 - ..
B10868 - Bob plans to call Doctor Rugo to discuss resolution of UCSF claims
B10869 - against Millie, based on referral documentation. He requested a
B10870 - letter on discussions today with documentation he can present for
B10871 - review with Kaiser and Doctor Rugo.
B10873 - [On 070831 letter to UCSF confirms understandings from meeting
B10874 - today, and submits background correspondence. ref SDS 34 PZ6T
B10876 - ..
B10877 - [On 070906 Doctor Rugo confirms in letter that Kaiser made the
B10878 - referral, and noted Medicare rules on clinical trials are very
B10879 - muddy. ref SDS 36 UK5M
Coinsurance Interim Payment Pending Justification Charges Doctor Vis
C00401 - ..
C00402 - Medicare Breaks Trust and Reliance between Patient and Doctor
C00403 - Coinsurance Interim Payment Doctor Visits Pending Justification
C00405 - Bob asked if Millie would be willing to make interim payment for
C00406 - coinsurance on doctor visits? He requested payment of about $25 for
C00407 - each time Millie has met with the doctor. We reviewed the record
C00408 - showing that Millie has been continually advised by the UCSF staff in
C00409 - the Breast Care Clinic that she does not owe copayments to visit the
C00410 - doctor, because these costs are paid by the clinical trial. Bob
C00411 - explained today that this might have been a mistake.
C00413 - ..
C00414 - Bob could not explain any correlation between UCSF billing for
C00415 - coinsurance, illustrated by the invoice #12593370 shown above for...
C00417 - 060407 1 0101005 DENIED CO-INSURANCE 202.65 202.65 202.65
C00419 - ...and any medical service Millie has received from UCSF. ref SDS 0
C00420 - WO8I There is nothing evident in this entry that correlates with
C00421 - payment for doctor visits or anything else listed in the UCSF invoice.
C00422 - ref SDS 0 I57O Bob related that Kaiser calculates all coinsurance
C00423 - charges and tells UCSF how much to bill the patient, per above.
C00424 - ref SDS 0 5W5G
C00426 - [On 070917 UCSF request for interim payment of conisurnace
C00427 - on doctor visits charged at $101.00 example of no
C00428 - correlation between charges and services performed by UCSF.
C00429 - ref SDS 38 WO6X
C00431 - ..
C00432 - [On 071128 Kaiser Appeals Committee approved payment for
C00433 - Millie's care on referral to UCSF. ref SDS 58 JZ5R
C00437 - ..
C00438 - Payment Dispute UCSF and Kaiser Resolution Objectives
C00439 - Goals for Resolution Dispute between Kaiser and UCSF
C00440 - UCSF Treatments Effective Continue Patient Objective Goals
C00442 - Millie wants to develop terms and conditions for continued treatment,
C00443 - based on effective results with cetuximab. On 070130 Doctor Rugo
C00444 - advised UCSF has other treatments that can benefit Millie, ref SDS 21
C00445 - TG5G, beginning with adding carboplatin when disease progresses.
C00446 - ref SDS 21 NI6K
C00448 - [On 070924 notify UCSF objective to develop financial
C00449 - footing for continuing treatment at UCSF. ref SDS 41
C00450 - UL5R
C00452 - ..
C00453 - [On 071030 notify Kaiser of objective to develop
C00454 - financial arrangemetns for continuing treatment at
C00455 - UCSF. ref SDS 56 UB5S
C00457 - ..
C00458 - [On 071128 Kaiser Appeals Committee approved payment
C00459 - for Millie's care on referral to UCSF. ref SDS 58 JZ5R
C00462 - ..
C00463 - 4 Problems Interjecting Medicare Between Kaiser and Patient
C00465 - UCSF's demand for coinsurance payments from Millie creates following
C00466 - problems...
C00468 - [On 070917 lessons learned require review to
C00469 - strengthen coinsurance process. ref SDS 38 8X8H
C00471 - ..
C00472 - [On 070921 Kaiser prescribes 4 tablets Atavin per day
C00473 - for treating anxiety from doubt and worry about
C00474 - getting treatments and billing problems. ref SDS 40
C00475 - QY9V
C00477 - ..
C00478 - [On 070927 16 issues arrise to resolve payment for
C00479 - Millie's care at UCSF. ref SDS 43 WU6M
C00481 - ..
C00482 - [On 071004 Medicare policy questions submitted to
C00483 - James Mayhew at CMS for review. ref SDS 44 P74W
C00485 - ..
C00486 - 1. Agreeing to pay coinsurance may be interpreted as relieving
C00487 - Kaiser of responsibility for having prescribed treatment at
C00488 - UCSF as the best course of care for a continuing condition
C00489 - by substituting the patient's judgement to "self-refer."
C00490 - Millie intends for Kaiser to retain responsibility for
C00491 - providing care of her continuing condition purchased by
C00492 - insurance premiums, as discussed at Kaiser on 061208.
C00493 - ref SDS 14 P27L On 061230 Kaiser discharged its duty to
C00494 - provide treatment for covered oncology services by
C00495 - coordinating with UCSF for treatment in a clinical trial,
C00496 - and making arrangements to pay any costs not covered by the
C00497 - trial. ref SDS 15 3X6K On 070105 the doctor notified
C00498 - Millie that Kaiser prescribed treatment of her cancer at
C00499 - UCSF, ref SDS 17 PK7L, which saved Kaiser the cost of
C00500 - paying for chemotherapy drugs. On 070119 the doctor
C00501 - confirmed authorization for treatment at UCSF was
C00502 - submitted. ref SDS 20 4R4M Additionally, Kaiser must
C00503 - retain accountability for correcting errors and omissions
C00504 - that may relate to medical practice in this case. The only
C00505 - reason Millie came to UCSF is because her doctor prescribed
C00506 - treatment. She did not sef-refer in order to participate
C00507 - in a clinical trial.
C00509 - ..
C00510 - [On 070924 notify UCSF 4 concerns about paying
C00511 - coinsurance. ref SDS 41 UL5R
C00513 - ..
C00514 - [On 070927 16 grounds for Kaiser to pay for Millie's
C00515 - treatment on referral to UCSF, ref SDS 43 WU6M, and
C00516 - one addresses requirement for Kaiser to retain
C00517 - responsibility for patient care. ref SDS 43 WV5G
C00519 - ..
C00520 - [On 071018 Doctor Rugo reported understandings that
C00521 - Millie was "cut loose" by Kaiser to fend for herself
C00522 - working with UCSF for treatment prescribed by Kaiser.
C00523 - ref SDS 50 W23I
C00525 - ..
C00526 - [On 071128 Kaiser Appeals Committee approved payment
C00527 - for Millie's care on referral to UCSF. ref SDS 58 JZ5R
C00529 - ..
C00530 - 2. Millie has always relied on her doctor for diagnosis and
C00531 - treatment paid for by her insurance policy with Kaiser, per
C00532 - above. ref SDS 0 T14M Coinsurance was not presented as a
C00533 - condition of treatment on 070105, ref SDS 17 P256, nor at
C00534 - any time until today. On 070829 Kaiser Member Services
C00535 - submitted documentation saying coinsurance may apply to
C00536 - participating in clinical trials, which supports the
C00537 - doctor's authority to prescribe treatment, ref SDS 32 SF4I,
C00538 - as occurred in this case. Millie is concerned that
C00539 - agreeing to pay coinsurance charges requested by UCSF
C00540 - disrupts trust and reliance on the doctor essential for
C00541 - effective care, and further creates open ended exposure to
C00542 - demands for payment, which Kaiser is obligated to pay for
C00543 - routine care in oncology practice, as explained by the
C00544 - doctor at Kaiser on 040318. ref SDS 5 PU6M Breaking trust
C00545 - of reliance on the doctor introduces a significant breach
C00546 - in the doctor patient partnership presented by Kaiser as
C00547 - the foundation of good care, reviewed on 990625.
C00548 - ref SDS 1 4185 This compromises and increases cost of
C00549 - case management by requiring the patient to question
C00550 - treatment decisions, demanding consultation with people who
C00551 - have authority to commit Kaiser. The doctor will need a
C00552 - committee in the examination room to prescribe treatment.
C00554 - ..
C00555 - [On 070927 Kaiser Senior Advantage EOC section 7
C00556 - describes coinsurance for patients who "self-refer" to
C00557 - clinical trials for advancing medical research,
C00558 - ref SDS 43 1G4O, which does not apply for Millie's
C00559 - treatment at UCSF prescribed by Kaiser for essential
C00560 - care, ref SDS 43 1F92, also explained on 070917,
C00561 - ref SDS 38 596Q; Kaiser EOC section 2 says the doctor
C00562 - must prescribe treatment needed for covered services,
C00563 - which includes oncology care. ref SDS 43 WS6M
C00565 - ..
C00566 - [On 071128 Kaiser Appeals Committee approved payment for
C00567 - Millie's care on referral to UCSF. ref SDS 58 JZ5R
C00570 - ..
C00571 - 3. Receiving 100 or so pages of invoices and statements that
C00572 - show no correlation between services provided and demands
C00573 - for payment with nebulous phrases like "account balance
C00574 - transfer," see example above, ref SDS 0 WO8M, creates an
C00575 - overwhelming physical and emotional cost of time and
C00576 - expertise for determining what to pay, as Bob noted today,
C00577 - per above. ref SDS 0 X16N This increases stress on cancer
C00578 - patients who are vulnerable to stress related maladies.
C00579 - Millie wants to streamline billings so that payments do not
C00580 - take an inordinate amount of time and expense for cognitive
C00581 - overhead (see NWO. ref OF 15 LH6K). UCSF and Kaiser have
C00582 - teams of accountants and specialists. Patients do not have
C00583 - this resource.
C00585 - [On 070921 emotional stress evident from rising
C00586 - inflammation and blood pressure, ref SDS 40 QY5I,
C00587 - doctor prescribes drugs and therapy. ref SDS 40 QY9V
C00589 - ..
C00590 - [On 070921 doctor reports (last sentence in narrative)
C00591 - patient experiencing panic attacks from billings for
C00592 - clinical trial treatment, ref SDS 40 NE4N; prescribes
C00593 - mental health consultation and drugs to treat
C00594 - emotional distress. ref SDS 40 WF8P
C00596 - ..
C00597 - 4. Responsibility to investigate Medicare requirements
C00598 - increases the burden of cognitive overhead for study and
C00599 - analysis that requires an overwhelming commitment of time,
C00600 - expense, and expertise in order to determine correctness of
C00601 - billings, illustrated by UCSF invoices above. ref SDS 0
C00602 - 4P8K
C00604 - [On 070917 review of Medicare law and regulations
C00605 - extremely complex for patient to determine amounts to
C00606 - pay for clincial trial treatment prescribed by Kaiser.
C00607 - ref SDS 38 596Q
C00609 - ..
C00610 - [On 070921 doctor notes pressures from rising
C00611 - regulatory complexity and costs of health care are
C00612 - transferred to cancer patients who are least able to
C00613 - cope and highly vulnurable to stress related maladies.
C00614 - ref SDS 40 CU58
Patient Agreement UCSF Obligations Deductables Copayments Required b
D20401 - ..
D20402 - Patient Agreement UCSF Obligations Discharged by Kaiser Insurance
D20404 - During the meeting today, complexity of Medicare requirements were
D20405 - illustrated by Millie's meeting with Kaiser yesterday at the Walnut
D20406 - Creek facility. ref SDS 32 EG5J Barbara Latino in the Customer
D20407 - Services Department on the 4th floor reviewed Millie's agreement with
D20408 - UCSF signed on 070412, saying in part...
D20410 - The undersigned accepts responsibility for all deductibles
D20411 - and co-payments that may be required by the patient's
D20412 - health insurance, including Medicare. ref SDS 32 RA6N
D20414 - ..
D20415 - Millie has discharged her responsibility to UCSF through her agent
D20416 - Kaiser accepting responsiblity for any costs not covered by the
D20417 - clinical trial, shown in the letter from the primary care physician on
D20418 - 061230 sent to Doctor Rugo at UCSF. ref SDS 15 3X6K
D20421 - ..
D20422 - Coinsurance Not Owed Kaiser Pays Costs Not Covered by Clinical Trial
D20423 - Kaiser Says Customers May Be Charged Coinsurance for Clinical Trials
D20425 - Barbara described Millie's case as very complex, and submitted Kaiser
D20426 - documents showing Medicare pays for clinical trials to help doctors
D20427 - and researchers discover better treatments. Medicare pays for blood
D20428 - tests required for clinical trials. ref SDS 32 RA85, which seems to
D20429 - conflict with UCSF invoicing discussed by Bob today, per above.
D20430 - ref SDS 0 T149 Barbara also cited documents saying Millie may be
D20431 - charged coinsurance, but she had never heard of this provision, and
D20432 - could not explain how much, who is paid, and the scope of services
D20433 - being coinsured, ref SDS 32 SF4I, which aligns with Bob's report today
D20434 - that nobody can explain UCSF billings to Millie, since all
D20435 - calculations are provided by Kaiser's Medicare unit, per above.
D20436 - ref SDS 0 WU5N
D20438 - [On 070917 UCSF submits revised claim that lowers the
D20439 - amount, possibly eliminating charges for blood tests.
D20440 - ref SDS 38 595P
D20442 - ..
D20443 - In this case, coinsurance does not apply because Millie did not
D20444 - self-refer. Kaiser prescribed treatment on 070105 to perform standard
D20445 - of care for oncology practice, and agreed with UCSF on 061230 for
D20446 - Kaiser to pay for any costs not covered by the clinical trial.
D20447 - ref SDS 17 PK68 (see case study listing correspondence between Kaiser
D20448 - and UCSF on Kaiser's referral. ref SDS 0 T247)
D20450 - ..
D20451 - [On 070906 Doctor Rugo confirmed that Kaiser made the
D20452 - referral. ref SDS 36 UK5M
D20454 - ..
D20455 - [On 070917 review shows coinsurance is aimed at supporting
D20456 - supplemental/secondary insurance in the private sector that
D20457 - provides Medigap coverage of coinsurance. ref SDS 38 TN3O
D20459 - ..
D20460 - [On 070917 Kaiser tells new members to cancel Medigap
D20461 - insurance coverage, because Kaiser Senior Advantage
D20462 - performs this scope. ref SDS 38 EZ56
D20464 - ..
D20465 - [On 071009 USACE representative claims to have received
D20466 - notice from unnamed people at Kaiser that the patient was
D20467 - told the patient would be responsible for coinsurance in
D20468 - Kaiser's transaction arranging for treatment on referral at
D20469 - UCSF. ref SDS 46 N88P
D20473 - ..
D20474 - Doctor Visits Copayments Requested by UCSF Conflicts Clinical Trial
D20475 - UCSF Requests Copayments Doctor Visits Identified as $101
D20476 - Patient Agrees Copayments for Doctor Visits Same as at Kaiser
D20478 - Bob showed his new spreadsheet submitted today, per above, ref SDS 0
D20479 - H54O, has a number of line items which he had checked with an ink pen.
D20480 - Each item shows a total charge of $101.00, which Bob advised are UCSF
D20481 - charges for doctor visits. However the amount UCSF wants Millie to
D20482 - pay varies from $22.88 to $27.88. Bob did not explain why the
D20483 - customer is charged a variable rate for coinsurance on a fixed charge
D20484 - to visit the doctor.
D20486 - ..
D20487 - Bob understands Millie's concern about lack of notice for extra
D20488 - charges until months after services were provided, thus denying the
D20489 - customer opportunity to make reasonable economic choices. He will
D20490 - investigate justification for charging Millie extra expense, and will
D20491 - submit results of findings to support UCSF's claims.
D20493 - [On 070831 letter confirms that UCSF must justify charges for
D20494 - extra expenses to Millie, including coinsurance. ref SDS 34
D20495 - PY9W
D20497 - ..
D20498 - [On 070904 Millie's letter to UCSF confirms demand for
D20499 - justification of charges, including coinsurance. ref SDS 35
D20500 - 6R4W
D20502 - ..
D20503 - [On 070906 Millie's letter submits interim payment for
D20504 - coinsurance. ref SDS 36 EB3P
D20506 - ..
D20507 - Bob seemed to recognize that Millie holds she owes UCSF no additional
D20508 - payments based on lack of justification in UCSF billings, and Kaiser's
D20509 - agreement to pay any costs not covered by the trial, per above.
D20510 - ref SDS 0 T247
D20512 - ..
D20513 - As a show of good faith, Bob again requested interim payment of
D20514 - coinsurance amounts he checked in ink on the spreadsheet, which total
D20515 - about $300, per above, ref SDS 0 W06L, of UCSF's immediate claim
D20516 - against Millie of $4,254.12, ref SDS 0 QW8M, and in order to
D20517 - demonstrate willingness to pay all reasonable and necessary costs
D20518 - which UCSF can justify. For example, there is nothing in UCSF
D20519 - invoices that say $101 is for doctor visits. Since Doctor Rugo
D20520 - recently decided to reduce doctor visits from twice a month to only
D20521 - once a month, in light of improvement in Millie's condition under
D20522 - clinical trial treatments, this makes charges for doctor visits
D20523 - nominal.
D20525 - ..
D20526 - To assist UCSF review toward developing a coordinated referral plan
D20527 - that aligns with everyone's duties and responsibilities, there was
D20528 - agreement today for Millie to pay the items of $101.00 checked in ink
D20529 - by Bob on the new spreadsheet received during the meeting. ref SDS 0
D20530 - WP5I Bob asked that Millie list on the check payable to UCSF for
D20531 - doctor visits the account numbers he checked on the spreadsheet.
D20533 - ..
D20534 - Bob will submit justification showing Millie should pay coinsurance
D20535 - for doctor visits.
D20537 - ..
D20538 - Bob said that if UCSF has erred and is not justified billing Millie,
D20539 - because Kaiser is responsible to pay for her care on referral to UCSF,
D20540 - then UCSF will refund this interim good faith payment back to Millie.
D20542 - [...problems caused by payment of coinsurance in this case
D20543 - are listed above. ref SDS 0 T94O
D20545 - ..
D20546 - [On 070831 letter confirms that UCSF must justify charges
D20547 - for extra expenses to Millie, including coinsurance.
D20548 - ref SDS 34 PY9W
D20550 - ..
D20551 - [On 070906 Millie submitted interim payment of $312.08 to
D20552 - UCSF for coinsurance, subject to justification and refund
D20553 - from UCSF in absence of such justification. ref SDS 36 EB3P
D20555 - ..
D20556 - [On 070917 UCSF revised claim reduced to $1,500, annualized
D20557 - reduction from $10K down to about $2K per year, ref SDS 38
D20558 - WO4O, which more than doubles copayment costs typically
D20559 - incurred for the work involved. ref SDS 38 G68H
D20561 - ..
D20562 - [On 070917 received UCSF explanation that coinsurance for
D20563 - clinical trials specified in CMS section 69.9; provides no
D20564 - guidance calculating amounts and patient responsibilities.
D20565 - ref SDS 38 596Q
D20567 - ..
D20568 - [On 070917 review shows coinsurance is aimed at supporting
D20569 - supplemental/secondary insurance in the private sector that
D20570 - provides Medigap coverage of coinsurance. ref SDS 38 TN3O
D20572 - ..
D20573 - [On 070917 Kaiser tells new members to cancel Medigap
D20574 - insurance coverage, because Kaiser Senior Advantage
D20575 - performs this scope. ref SDS 38 EZ56
D20577 - ..
D20578 - [On 071128 1201 Millie notified that Kaiser agreed that
D20579 - Kaiser is liable for the cost of her care on referral to
D20580 - UCSF. ref SDS 58 TH8L
Distribution. . . . See "CONTACTS"