CONTACTS
0201 - UCSF Medical Center
020101 - Mr. Robert Zvi Schwartz, MPH
020102 - Patient Financial Consultant
020104 - Patient Financial Services
SUBJECTS
UCSF Cannot Justify Claim Against Millie for Treatment Clinical Tria
2703 -
2703 - ..
2704 - Summary/Objective
2705 -
270501 - Follow up ref SDS 31 0000. ref SDS 30 0000.
270502 -
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
270534 -
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
270583 -
270584 -
270585 -
270586 -
270587 -
270589 - ..
2706 -
2707 -
2708 - Progress
2709 -
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
270904 -
270905 - Follow up ref SDS 32 EF7L.
270906 -
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...
270936 -
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...
270950 -
270951 - UCSF Facility Billing
270953 - Date: September 30, 2007
270954 -
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%
270984 -
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
271049 -
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
271067 -
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
271081 -
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
271088 -
271089 - Follow up ref SDS 30 RV6U.
271090 -
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
271120 -
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.
271157 -
271158 -
271159 -
2712 -
SUBJECTS
Collection Billings Erroneous Charges Medical Services Entitlement P
5503 -
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
550405 -
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?
550413 -
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.
550429 -
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...
550475 -
550476 - Abraham Wax PC
550477 - Attorney at Law
550478 - 750 Third Avenue
550479 - New York, NY 10017
550480 - 212 922 9004
550481 -
550482 - http://www.abew.com/
550484 - ..
550485 - Assist health care providers collect health care claims
550486 - from insurance companies, ERISA plans, and Medicare.
550487 -
550488 -
550489 -
550490 -
550491 -
5505 -
SUBJECTS
Kaiser Blood Tests Rejects Payment Medicare Required for Routine Car
8503 -
850401 - ..
850402 - Kaiser May be Rejecting Medicare Payment for Blood Tests
850403 - Blood Tests Lab Costs Routine Care Trials Kaiser Charges Millie
850404 -
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.
850420 -
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
850444 -
850445 -
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
850452 -
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...
850479 -
850480 -
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
850547 -
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
850597 -
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
850669 -
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
850729 -
850730 - [On 070831 letter to UCSF explains image (CT) testing practical
850731 - performed at Kaiser and submitted to UCSF. ref SDS 34 PZ4X
850732 -
850733 -
850735 - ..
850736 - Lab Blood Tests Essential for Realtime Monitor Chemotherapy Care
850737 -
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
850755 -
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
850781 -
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
850797 -
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
850845 -
850846 -
850847 -
8509 -
SUBJECTS
Claim $10K UCSF Against Patient for Self-referral Medicare Coinsuran
B103 -
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
B10405 -
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.
B10413 -
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
B10429 -
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
B10446 -
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
B10476 -
B10477 -
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
B10484 -
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...
B10502 -
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
B10656 -
B10657 -
B10659 - ..
B10660 - Insurance Senior Advantage Since 2002 Why Extra Charges in 2007??
B10661 -
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
B10754 -
B10756 - ..
B10757 - Documentation at UCSF Shows Kaiser Referred Millie for Treatment
B10758 -
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...
B10770 -
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.
B10799 -
B10801 - ..
B10802 - Kaiser's Self-referral Theory Conflicts Patient History
B10803 - Patient Benefits Do Not Shield Kaiser from Paying for Prescribed Care
B10804 -
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.
B10817 -
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
B10829 -
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
B10858 -
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.
B10872 -
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
B10880 -
B10881 -
B10882 -
B10883 -
B10884 -
B109 -
SUBJECTS
Coinsurance Interim Payment Pending Justification Charges Doctor Vis
C003 -
C00401 - ..
C00402 - Medicare Breaks Trust and Reliance between Patient and Doctor
C00403 - Coinsurance Interim Payment Doctor Visits Pending Justification
C00404 -
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...
C00416 -
C00417 - 060407 1 0101005 DENIED CO-INSURANCE 202.65 202.65 202.65
C00418 -
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
C00425 -
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
C00434 -
C00435 -
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
C00441 -
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
C00447 -
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
C00460 -
C00462 - ..
C00463 - 4 Problems Interjecting Medicare Between Kaiser and Patient
C00464 -
C00465 - UCSF's demand for coinsurance payments from Millie creates following
C00466 - problems...
C00467 -
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
C00568 -
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.
C00584 -
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
C00603 -
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
C00615 -
C00616 -
C00617 -
C007 -
SUBJECTS
Patient Agreement UCSF Obligations Deductables Copayments Required b
D203 -
D20401 - ..
D20402 - Patient Agreement UCSF Obligations Discharged by Kaiser Insurance
D20403 -
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...
D20409 -
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
D20419 -
D20421 - ..
D20422 - Coinsurance Not Owed Kaiser Pays Costs Not Covered by Clinical Trial
D20423 - Kaiser Says Customers May Be Charged Coinsurance for Clinical Trials
D20424 -
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
D20437 -
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
D20470 -
D20471 -
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
D20477 -
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.
D20492 -
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.
D20541 -
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
D20581 -
D20582 -
D20583 -
D20584 -
D20585 -
D20586 -
D20587 -
D20588 -
D20589 -
D20590 -
D20591 -
D20592 -
D20593 -
D206 -
Distribution. . . . See "CONTACTS"