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 -