THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net
S U M M A R Y
DIARY: August 31, 2007 05:39 PM Friday;
Rod Welch
Letter to UCSF confirm planning to resolve billing issues for Millie.
1...Summary/Objective
........Who Speaks for Patient in Negotiations Between UCSF and Kaiser?
............"Section 2: What's Covered"
........Payment No Justification Beyond Insurance Premiums
..............
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CONTACTS
0202 - UCSF Medical Center O-00000875 0305
020201 - Mr. Robert Zvi Schwartz, MPH O-00000875 0305
020202 - Patient Financial Consultant
020204 - Patient Financial Services
SUBJECTS
UCSF Claim $10K Not Justified Against Millie for Treatment Clinical
2803 -
2803 - ..
2804 - Summary/Objective
2805 -
280501 - Follow up ref SDS 11 0000, ref SDS 10 0000.
280502 -
280503 - Letter to UCSF reports results of meeting with the accounting
280504 - department yesterday for explanation of billings to get treatment in a
280505 - clinical trial.
280506 -
280507 -
280508 -
280509 -
280511 - ..
2806 -
2807 -
2808 - Progress
2809 -
280901 - Submitted ref DIT 1 0001 to Jackie at UCSF for distribution to Doctor
280902 - Rugo, and copies to Bob Schwartz in UCSF accounting, and to Arlette
280903 - for distribution to the primary care physician at Kaiser...
280904 -
280905 - 1. Millie was elated by decline of the blood test for CA 15-3 to
280906 - 28, reported in your letter this morning. Improved cancer
280907 - marker diagnostics aligns with months of favorable CT testing,
280908 - continuing improvement under Doctor Rugo's care at UCSF ordered
280909 - by Kaiser on 070105. ref SDS 3 PK7L, ref DIT 1 0001
280910 -
280911 - [On 070904 Millie letter to Doctor Rugo requests assistance
280912 - resolving billing problems between Kaiser and UCSF.
280913 - ref SDS 12 G15I
280915 - ..
280916 - [On 070909 letter to Kaiser and to UCSF notifying of
280917 - dispute over coinsurance which conflicts with agreement on
280918 - 061230 that Kaiser would pay for any costs not covered by
280919 - clinical trial, ref SDS 14 6O4U, and submitting interim
280920 - payment of copayments for doctor visits, pending submission
280921 - of justification for charges when UCSF represents that cost
280922 - of doctor visits are paid by the clinical trial.
280923 - ref SDS 14 XM4F
280925 - ..
280926 - 2. Favorable cancer marker is a great send off for her vacation
280927 - next week. ref DIT 1 GG67
280929 - ..
280930 - 3. By copy to Arlette, I am notifying [the primary care physician]
280931 - at Kaiser to update Millie's medical chart to prepare for
280932 - meeting with Millie scheduled next month, as part of Kaiser's
280933 - continuing care, control, and responsibility for this case.
280934 - ref DIT 1 GG65
280935 -
280936 - [On 070921 medical chart for meeting at Kaiser does not
280937 - show current blood test results; reports results from 5
280938 - months ago. ref SDS 16 WF5Q
280940 - ..
280941 - 4. As we discussed yesterday, I met with Bob Schwartz at UCSF
280942 - accounting offices on Harrison Street to review billing issues
280943 - that have come up the past few weeks, ref SDS 11 0001, when
280944 - Millie suddenly received a rash of about 30 documents from UCSF
280945 - and an equal number from Kaiser backdated for work beginning on
280946 - or about January 30, 2007, when Millie met with Doctor Rugo and
280947 - her clinical trial team at UCSF to start treatment for IBC with
280948 - cetuximab. ref DIT 1 GG77
280950 - ..
280951 - 5. Bob seemed unaware that Millie had been treated for 7 or 8
280952 - months without getting invoices. ref SDS 11 RG8H ref DIT 1 GG85
280953 - This is evident from UCSF's invoice for work on 070301 dated 5
280954 - months later on 070823, which Bob discussed yesterday.
280955 - ref SDS 11 4P8K
280957 - ..
280958 - 6. Bob explained yesterday that UCSF billings for services to date
280959 - in the approximate amount of $4,300, ref SDS 11 H54O, will be
280960 - increasing because of additional work UCSF has performed since
280961 - the initial statement received a few weeks ago. Just guessing
280962 - this appears to roll up to about $10K for the year. ref SDS 11
280963 - W05N, ref DIT 1 GG84
280965 - ..
280966 - 7. Bob was very helpful explaining UCSF billings to the patient
280967 - are based solely on mathematical manipulations presented by
280968 - Kaiser acting as an agent for Medicare. He pointed out that to
280969 - support cost containment UCSF and Kaiser through its Medicare
280970 - affiliate have entered into contractual agreement on amounts to
280971 - compensate UCSF for reasonable and necessary costs of services.
280972 - ref SDS 11 WU5N, ref DIT 1 GG97
280974 - ..
280975 - 8. UCSF then bills Kaiser as services are performed and coded by
280976 - the doctor to correlate with approved cost accounts. Kaiser
280977 - makes payments in accordance with the contract. Bob further
280978 - explained that Kaiser tells UCSF the amount it has over-billed
280979 - based on Kaiser's understanding of the contract; but that
280980 - experts (he and colleagues) in the UCSF accounting department
280981 - routinely call their counterparts at Kaiser and negotiate on
280982 - application of Medicare regulations, which results in Kaiser
280983 - agreeing to pay UCSF more money. ref SDS 11 WU5N ref DIT 1 GG97
280985 - ..
280986 - 9. As shown in the record on 070823, UCSF and Kaiser go through
280987 - many iterations of negotiation for each transaction before
280988 - finally settling on payment to UCSF. ref SDS 9 X05R,
280989 - ref DIT 1 GG46
280991 - ..
280992 - 10. This makes a lot of sense, because contracts can be reasonably
280993 - interpreted in many ways to equitably execute complex medical
280994 - transactions. ref DIT 1 GG59
280996 - ..
280997 - 11. This aligns with Millie's experience when she was referred by
280998 - her doctor on June 28, 2002 to get treatment at Mt Diablo
280999 - hospital, which was not available at Kaiser. As you can see,
281000 - there was no disclosure of extra expenses; rather, in the
281001 - absence of disclosure notifying of additional expense, which
281002 - the patient could decide proactively to accept or request a
281003 - showing of justification, alternatives, etc., Millie reasonably
281004 - relied on tacit understanding that what the doctor ordered was
281005 - part of insurance coverage, the same as if performed by Kaiser.
281006 - ref SDS 1 QB5Q, ref DIT 1 GG5F
281008 - ..
281009 - 12. There was no discussion of Millie getting invoices for
281010 - "miscellaneous expenses," and in fact she never saw an invoice
281011 - for referral work at Mt Diablo. ref DIT 1 GG68
281013 - ..
281014 - 13. Similarly, in this case, Millie was told by her doctor on
281015 - January 5, 2007 that he made a referral for treatment at UCSF
281016 - that was not available at Kaiser for her "triple negative
281017 - status". ref SDS 3 PK7L, ref DIT 1 GH33
281019 - ..
281020 - 14. As with the prior experience, Millie relied on her doctor that
281021 - treatment at UCSF would be paid under her insurance the same as
281022 - if performed at Kaiser. Additionally, the doctor notified
281023 - Millie in a letter on December 30, 2006 transmitting
281024 - correspondence between Kaiser and UCSF on referral arrangements
281025 - which expressly indicate Millie would have no additional costs,
281026 - including standard of care. ref SDS 2 3X6K, ref DIT 1 GH35
281028 - ..
281029 - 15. Subsequently, Millie was notified by UCSF to begin treatment in
281030 - San Francisco on January 19, 2007 because her condition was
281031 - worsening as a result of Kaiser ending prior treatment on
281032 - December 1, 2006, which had become ineffective. ref SDS 4 AS9L,
281033 - ref DIT 1 GH46
281035 - ..
281036 - 16. As shown in the record, Doctor Rugo, her assistant, Jackie, and
281037 - everyone at Kaiser, including ...the primary care physician at
281038 - Kaiser worked very hard over the next several weeks to resolve
281039 - referral authorization issues, beginning with [Kaiser's Doctor
281041 - letter to Millie on January 19th, which says in part...
281043 - ..
281044 - "[Kaiser] Authorization was submitted [to UCSF]...but, new
281045 - Medicare regulations around this are confusing. Dr Rugo
281046 - and I are working on it from both ends." ref SDS 4 4R4M,
281047 - ref DIT 1 GH54
281049 - ..
281050 - 17. As a result, Millie was sent home on January 19th without
281051 - treatment, so that Kaiser and UCSF could resolve payment
281052 - issues. ref DIT 1 GH6F
281054 - ..
281055 - 18. Millie was called a few weeks later and told the issue was
281056 - resolved, and then met with Doctor Rugo at UCSF on January
281057 - 30th. At that time, she was not asked for payment. ref SDS 5
281058 - SM6M, ref DIT 1 GH79
281060 - ..
281061 - 19. During the meeting on January 30th, the doctor indicated that
281062 - authorization and payment issues had been resolved. ref SDS 5
281063 - LC60, ref DIT 1 GH7A
281065 - ..
281066 - 20. In light of this history, Millie was upset to start getting
281067 - invoices a few weeks ago for services beginning in January.
281068 - ref DIT 1 GH8F
281070 - ..
281071 - 21. Discussion with Bob yesterday, seemed to indicate that UCSF is
281072 - counting on Kaiser's Medicare reps to designate amounts they
281073 - should bill the patient. There seems to be no correlation
281074 - between any amount in UCSF billings to any specific service
281075 - performed for the patient. ref SDS 11 WU5N, ref DIT 1 GH8C
281077 - ..
281078 - [On 070917 research of Title 42 part 419.40 indicates rates
281079 - for payment of various types (APC groups) of medical
281080 - services are determined annually by Medicare which suggests
281081 - these amounts are known in advance of entering treatment
281082 - agreements. ref SDS 15 4Q3I
281084 - ..
281085 - [On 070917 limitations on annual amount of coinsurance
281086 - patients owe under Medicare. ref SDS 15 TN4N
281088 - ..
281089 - 22. Bob cited two general classes of payment he believes Kaiser is
281090 - designating for collection by UCSF from Millie. There is no
281091 - documentation showing either entitlement nor alignment with
281092 - amounts in UCSF accounts. Bob related having talked to Barbara
281093 - in Kaiser's Outside Referral office, and he drew from that
281094 - telephone discussion that someone in Kaiser's Medicare unit
281095 - wants Millie to pay for something being called "co-insurance"
281096 - for each time she visits with Doctor Rugo. He said these can
281097 - be recognized by 8 separate charges of $101.00 on a spreadsheet
281098 - he prepared that is undated, but shows activity through August
281099 - 2, 2007. ref SDS 11 VT5W, ref DIT 1 GH9H
281101 - ..
281102 - 23. He explained that the column showing "Patient Responsibility"
281103 - should be paid by Millie. While the amount of $101 is the same
281104 - for all 8 charges, the amount of patient responsibility varies
281105 - from $22.26 to $27.88. Naturally, we don't want to bog down
281106 - high priced professionals over a few dollars, but the question
281107 - arises about the basis for these charges, and the variance?
281108 - ref SDS 11 VT5W, ref DIT 1 GH4B
281110 - ..
281111 - 24. Bob explained UCSF standard practice to submit unpaid amounts
281112 - to a collection agency, or alternatively, the patient can claim
281113 - indigent status, and UCSF seeks recovery from various charity
281114 - sources. ref SDS 11 9K7G, ref DIT 1 GH5H
281115 -
281117 - ..
281118 - Who Speaks for Patient in Negotiations Between UCSF and Kaiser?
281119 -
281120 - 25. What was unclear in the meeting, was why, if UCSF can negotiate
281121 - over and over with counterparts at Kaiser to reach equitable
281122 - adjustment of admittedly confusing regulations in order to
281123 - increase payment to UCSF, reported on 070823, ref SDS 9 X05R,
281124 - who is speaking for the patient? If there is no charge for
281125 - "office visits" to patients in clinical trials, what is the
281126 - basis of charging "co-insurance" for office visits. Where is
281127 - the requirement for "co-insurance" specified? [as discussed
281128 - with Bob on 070830] ref SDS 11 VT5W, ref DIT 1 GH5F
281129 -
281130 - [On 070917 received UCSF explanation that coinsurance for
281131 - clinical trials specified in CMS section 69.9; provides no
281132 - guidance calculating amounts and patient responsibilities.
281133 - ref SDS 15 596Q
281135 - ..
281136 - [On 070917 review shows coinsurance is aimed at supporting
281137 - supplemental/secondary insurance in the private sector that
281138 - provides Medigap coverage of coinsurance. ref SDS 15 TN3O
281140 - ..
281141 - [On 070917 Kaiser tells new members to cancel Medigap
281142 - insurance coverage, because Kaiser Senior Advantage performs
281143 - this scope. ref SDS 15 EZ56
281145 - ..
281146 - 26. During the meeting, agreement was reached to give UCSF payment
281147 - for these office visit charges. ref SDS 11 W141 At that time,
281148 - we did not take time to check the record on why Millie had not
281149 - been making these payments. As noted, subsequent review shows
281150 - no support for these charges. ref SDS 11 W141, ref DIT 1 GH6E
281152 - ..
281153 - 27. Bob asked that the account number on his spreadsheet be listed
281154 - on the check, and indicated payment can be submitted to the
281155 - UCSF Administrative Office on the ground floor at 1600
281156 - Divisadero, when Millie goes in for treatment next Thursday,
281157 - September 6th. ref SDS 11 V373 In turn, Millie requests that
281158 - UCSF submit controlling authority on this issue. Are patients
281159 - in clinical trials required to pay for office visits, if so,
281160 - why wasn't this disclosed on January 19th at the first meeting,
281161 - or on January 30th at the 2nd meeting, or on any of the other
281162 - meetings? Why was notice and explanation of charges withheld
281163 - for 8 months until August 30th? ref SDS 11 T25H, ref DIT 1 GI3B
281165 - ..
281166 - 28. Bob's report that Kaiser designates as "Patient Responsibility"
281167 - the cost of blood tests does not withstand scrutiny.
281168 - ref SDS 11 T149 He examined account #12593370 for services on
281169 - March 1, 2007. UCSF submitted payment request to Kaiser for
281170 - $4,549.49. Kaiser eventually paid UCSF $1,776.54 after several
281171 - negotiations. ref SDS 11 4P8K Bob seemed to explain further
281172 - that the column marked "Contractual Adjustment" reflects the
281173 - amount the Kaiser Medicare rep feels was overbilled in relation
281174 - to pre-established billing rates in the contract with UCSF. He
281175 - explained that Kaiser then calculates an amount which UCSF can
281176 - collect from the patient in a column called "Patient
281177 - Responsibility." Bob emphasized there is no attempt to
281178 - correlate this amount to any Medicare regulation nor to any
281179 - provision in the patient's agreement with Kaiser, rather this
281180 - is a simple arithmetic calculation. As a result, he said the
281181 - doctor cannot notify the patient that charges are being
281182 - accumulated, because the only way UCSF can determine what to
281183 - bill the patient is after they complete negotiations with
281184 - Kaiser. ref DIT 1 GI4D
281185 -
281186 - [On 070917 UCSF submitted revised spreadsheet eliminating
281187 - all extra charges except for coinsurance for which recovery
281188 - is claimed in the amount of $1,506.60. ref SDS 15 J14R
281190 - ..
281191 - [On 070917 review shows coinsurance is aimed at supporting
281192 - supplemental/secondary insurance in the private sector that
281193 - provides Medigap coverage of coinsurance. ref SDS 15 TN3O
281195 - ..
281196 - [On 070917 Kaiser tells new members to cancel Medigap
281197 - insurance coverage, because Kaiser Senior Advantage performs
281198 - this scope. ref SDS 15 EZ56
281200 - ..
281201 - 29. We need a coordination plan to identify charges so the patient
281202 - can exercise control of expenses in the same way that UCSF and
281203 - Kaiser have established a cost-basis for performing Medicare
281204 - work. ref DIT 1 GI5K
281206 - ..
281207 - 30. Bob illustrated this fact by turning to UCSF's list of detailed
281208 - charges and Kaiser's calculations on account 12593370 for
281209 - services on March 1, 2007. There is correlation between the
281210 - amount UCSF billed in the invoice of $4,549.49 and the amount
281211 - on Bob's spreadsheet summary, but there is nothing showing
281212 - support for Patient Charges of $1,240.96. ref SDS 11 MF4Q Bob
281213 - initially pointed to page 2 to support his understanding from
281214 - discussions with Barbara in Kaiser's Outside Referral
281215 - Department that Kaiser wants the patient to pay for blood
281216 - tests. He noted there is an amount of $202.65 for "denied
281217 - co-insurance," discussed above, and there is another amount of
281218 - $1028.31 for "Account balance transfer." He initially felt
281219 - this was for blood tests, but he then decided that the amount
281220 - for "LAB" of "$2,000.00" conflicts with this understanding.
281221 - ref SDS 11 WO5M, ref DIT 1 GI6G
281223 - ..
281224 - 31. Talking to Bob yesterday, we reviewed a meeting at Kaiser the
281225 - day before on Wednesday, August 29th. ref SDS 11 RW4J Millie
281226 - and I met with another Barbara in Kaiser's Customer Services
281227 - office at the Walnut Creek facility where Millie sees her
281228 - primary care physician. ref SDS 10 EF7L At that time, Barbara
281229 - in the Customer Services office investigated why Millie would
281230 - be charged for treatment on a clinical trial when Medicare
281231 - regulations pay for clinical trials. ref SDS 10 RA85,
281232 - ref DIT 1 GI7K
281234 - ..
281235 - 32. Barbara submitted a Kaiser document with the title...
281237 - ..
281238 - "Section 2: What's Covered"
281240 - ..
281241 - 33. She pointed to a section at the bottom that says...
281242 -
281243 - "Clinical Laboratory Services Including blood tests,
281244 - urinalysis, some screening tests, and more." ref DIT 1 KF4M
281246 - ..
281247 - "Clinical trials to help doctors and researchers find
281248 - better ways to prevent, diagnose, or treat diseases.
281249 - Routine costs are covered..." ref SDS 10 RA85
281251 - ..
281252 - 34. Barbara then pointed to a footnote at the bottom of the page
281253 - that says...
281254 -
281255 - "Note: coinsurance and/or deductibles may apply."
281256 - ref DIT 1 UG5I
281258 - ..
281259 - 35. Barbara handed Millie another printed paper with the title:
281260 - Medicare Clinical Trials. She explained having printed this
281261 - from a website. ref SDS 10 SF52 Barbara pointed to a section
281262 - that says...
281264 - ..
281265 - "Medicare will pay for many, but not all, services
281266 - associated with qualifying Clinical Trials. You should ask
281267 - the Clinical Trial provider if the Clinical Trial qualifies
281268 - for Medicare payments, and what Medicare coinsurance and
281269 - other out-of-pocket expenses you will have to pay."
281270 -
281271 - [On 070906 Kaiser's guidance calls for clinical trial
281272 - provider to disclose costs before starting treatments in
281273 - a clinical trial, ref SDS 13 SC71; clinical trial
281274 - director did not know patient would be charged
281275 - out-of-pocket expenses. ref SDS 13 I49K
281276 -
281278 - ..
281279 - Payment No Justification Beyond Insurance Premiums
281280 -
281281 -
281282 - 36. Since it appears from Barbara's research that "Clinical
281283 - Laboratory Services, including blood tests, urinalysis, some
281284 - screening tests, and more" are covered by Medicare, and since
281285 - there is no evident correlation between UCSF billings for
281286 - services and amounts being charged the patient, there is no
281287 - basis for the patient to make payment beyond premiums paid to
281288 - Kaiser and to Medicare. ref DIT 1 GI5M
281290 - ..
281291 - 37. We should try to meet with Kaiser's Medicare people to get
281292 - justification for allocation of charges. ref SDS 11 VT7G To
281293 - facilitate discussion of blood testing at UCSF, beyond the
281294 - clear language in Kaiser's documentation received on August
281295 - 29th, ref SDS 0 EW7O, discussion between Doctor Rugo and [the
281296 - primary care physician at Kaiser] on December 30th is
281297 - instructive when Kaiser gave assurances that Kaiser would pay
281298 - for "standard of care." ref SDS 2 3X6K ref DIT 1 GI6K
281300 - ..
281301 - 38. Laboratory tests are materially different from image testing,
281302 - e.g., xrays, CT, PET, etc. Patient history in this case shows
281303 - that image testing which is required by the clinical trial
281304 - protocol is effective performed by Kaiser, because it requires
281305 - reviewing prior test results for trend analysis to alert the
281306 - doctor of correlations, implications and nuance that are not
281307 - evident from a mere glance at figures. Lead time required for
281308 - this work is several days up to a week. [discussed with UCSF on
281309 - 070830. ref SDS 11 636H], ref DIT 1 GI6T
281311 - ..
281312 - 39. Blood tests are much different. Analysis essentially occurs on
281313 - the spot by the doctor and the nurse, and often requires
281314 - additional spot testing to verify the patient can get
281315 - treatment, or can be released to go home, etc., discussed with
281316 - Bob at UCSF yesterday. ref SDS 11 T176 Logistics of
281317 - transportation present an initial requirement for local control
281318 - of blood testing. Another problem is communication. There was
281319 - an attempt to perform blood testing at Kaiser and have results
281320 - submitted to UCSF. As shown in the record on January 30th,
281321 - this was not effective. ref SDS 5 MP4H, ref DIT 1 GJ3T
281322 -
281323 - [On 071017 problems ordering blood tests at Kaiser the
281324 - day before treatment at UCSF - Jackie faxes request for
281325 - blood draw to Arlette at Kaiser in Walnut Creek, Millie's
281326 - main treatment location. ref SDS 17 Q45F Arlette is at
281327 - lunch, delay finding out where to get blood drawn.
281328 - ref SDS 17 4Q5M Arlette advises UCSF blood draw request
281329 - was ordered by the doctor; tells customer to coordinate
281330 - with Kaiser to schedule blood draws. ref SDS 17 4Q7G
281331 - Kaiser in Walnut Creek cannot do blood draw until next
281332 - week, ref SDS 17 YE9G; Millie goes to Kaiser in Martinez
281333 - for the blood draw; finds the order is not entered in the
281334 - computer, ref SDS 17 OS3F; blood draw performed using
281335 - order found in the computer for prior blood draw from
281336 - last January. ref SDS 17 OS5K
281338 - ..
281339 - [On 071018 blood test results were not available for review
281340 - during examination, ref SDS 18 HL7O, treatment at UCSF was
281341 - delayed for an hour or so until Kaiser submitted blood test
281342 - results via fax. ref SDS 18 6N9F
281344 - ..
281345 - 40. Millie had 3 or 4 extra blood tests ordered by Kaiser which
281346 - were not needed, and which are avoided by deferring the test
281347 - until it is actually needed. To save time and money for Kaiser
281348 - and UCSF, this work was then performed by UCSF. [see case study
281349 - on 070130, ref SDS 6 2X6L], ref DIT 1 GJ4V
281351 - ..
281352 - 41. Millie's patient history listed most recently during the
281353 - meeting at Kaiser on May 25th, showing some 45 issues,
281354 - ref SDS 7 LU3J, presents a fragile condition subject to
281355 - momentary failure, which requires blood tests at the discretion
281356 - of the medical team. Doctor Rugo and Doctor Johnson should be
281357 - commended for outstanding care that demonstrates the model of
281358 - effective collaboration to save lives, time and money,
281359 - illustrated by emergency work for Millie at UCSF on June 7th.
281360 - ref SDS 8 0001, ref DIT 1 GJ5R
281362 - ..
281363 - 42. Thanks again to Bob for hard work preparing a spreadsheet that
281364 - organizes the raft of complex invoices, and for taking time
281365 - yesterday to explain UCSF billing practices. As [Millie's
281366 - primary care physician] noted on January 19th, more work is
281367 - needed to develop procedures to implement Medicare regulations.
281368 - ref SDS 4 4R4M Arlette, Oncology staff assistant indicated on
281369 - Wednesday, 070829, that Millie is their first patient being
281370 - treated under new procedures, ref SDS 10 EG4N, so all of us
281371 - have to work together, as trail blazers toward equitable and
281372 - cost efficient implementation. ref DIT 1 GJ6W
281374 - ..
281375 - 43. As well, getting a stage IV cancer patient who has relapsed 4
281376 - times to the point of NED on CT testing, and now today
281377 - registering the lowest cancer marker in 7 years of treatment
281378 - shows progress beyond belief implementing the tools of
281379 - medicine. Let's work toward the same result coordinating
281380 - accounting and billing between venerable organizations.
281381 - ref DIT 1 GJ7W
281383 - ..
281384 - 44. Jackie, as noted, I am sending a copy to Arlette for [the
281385 - primary care physician].
281387 - Please submit a copy to Doctor Rugo so she has a
281388 - chance to review the record in advance of getting a call from
281389 - Bob to help work through these matters, per the meeting
281390 - yesterday when Bob indicated he would
281391 - call the doctor.
281392 - ref DIT 1 GH8L
281393 -
281394 -
281395 -
281396 -
281397 -
281398 -
281399 -
281400 -
2815 -