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
Payment Medicare Coinsurance Interim Issued UCSF Justification Requi
4003 -
4003 - ..
4004 - Summary/Objective
4005 -
400501 - Follow up ref SDS 14 0000. ref SDS 13 0000.
400502 -
400503 - Millie submitted payment of $312 to UCSF for coinsurance, ref SDS 0
400504 - EB3P, based on UCSF promise to submit justification of charges for
400505 - doctor visits, ref SDS 0 EA5V, even though UCSF has previously
400506 - maintained patients in the clinical trial do now owe payment for
400507 - doctor visits. ref SDS 0 KC8S UCSF response by Doctor Rugo confirmed
400508 - that Kaiser made the referral for Millie's treatment in the clinical
400509 - trial at UCSF. The doctor further confirmed that UCSF did not know of
400510 - any out-of-pocket expenses for the patient. ref SDS 0 UK5M
400511 -
400512 -
400513 -
400514 -
400516 - ..
4006 -
4007 -
4008 - Progress
4009 -
400901 - Call Medicare Explanation UCSF Invoices
400902 - UCSF Customers Must Call Medicare for Justification of UCSF Invoices
400903 -
400904 - Follow up ref SDS 14 G15I.
400905 -
400906 - Millie submitted ref DIT 1 0001 to Doctor Rugo at UCSF with copies to
400907 - Jackie, Bob Schwartz in the accounting department, and to the primary
400908 - care physician at Kaiser. This letter submits interim payment for
400909 - coinsurance subject to justification, as set out in Millie's letter,
400910 - ref DIP 2 0001, submitted to Doctor Rugo a few days ago on 070904.
400911 - ref SDS 14 G15I
400913 - ..
400914 - Millie says to Doctor Rugo...
400915 -
400916 - 1. Following my letter, ref DIP 2 0001, to UCSF on September 4th,
400917 - ref SDS 14 G15I, Bob Schwartz in the UCSF accounting office
400918 - indicated in a telephone call that patients should contact
400919 - Medicare for explanation of UCSF charges for participation in
400920 - clinical trials. ref DIT 1 0001
400921 -
400922 - [...in another record today, Arlette submitted Kaiser
400923 - internal guidance on clinical trials for Senior
400924 - Advantage beneficieries, ref SDS 15 WC5S, who are
400925 - charged coinsurance; no amount is reported. ref SDS 15
400926 - WD3Y
400928 - ..
400929 - 2. Review shows coinsurance is widely disputed, illustrated by a
400930 - letter issued by the Cancer Leadership Council dated November
400931 - 30, 2006, ref DIT 1 WM62, and addressed to...
400932 -
400933 - http://www.cancerleadership.org/policy/clinic_medicare/061130.html
400934 -
400935 - [On 070917 Medicare statute Title 42 section 419.40
400936 - explains coinsurance minimum 20% for participation of
400937 - private insurance market coverage Medigap secondary,
400938 - supplemental insurance, ref SDS 18 4Q3I, which must pay
400939 - for coinsurance. ref SDS 18 IP8L Medigap must pay for
400940 - coinsurance on clinical trials. ref SDS 18 LN9W
400942 - ..
400943 - Kimberly Long
400944 - Medicare Coverage Advisory Committee
400945 - Centers for Medicare & Medicaid Services
400946 - Office of Clinical Standards and Quality,
400947 - Coverage and Analysis Group
400948 - 7500 Security Blvd. ? C1-09-06
400949 - Baltimore, Maryland 21233
400950 -
400951 - ...and stating in part...
400952 -
400953 - ...one of the challenges implementing the clinical trials
400954 - policy has been the lack of a reliable and consistent
400955 - definition of "routine costs" in clinical trials.
400956 - ref DIT 1 WM62
400958 - ..
400959 - We urge CMS to adjust payments to managed care plans to
400960 - reflect the costs that have been associated with the
400961 - National Coverage Decision on routine patient care costs
400962 - in clinical trials. This adjustment is necessary to ensure
400963 - that beneficiaries will have access to clinical trials
400964 - according to the terms of their managed care plans and not
400965 - as fee-for-service claims with 20% copayment. If efforts
400966 - to boost enrollment in managed care plans are successful,
400967 - this will become an even more serious problem. Therefore,
400968 - we urge immediate action to address it.
400970 - ..
400971 - 3. Another source says in part... ref DIT 1 WM8Q
400972 -
400973 - Kaiser Permanente Senior Advantage
400974 - Evidence of Coverage for
400975 - CITY OF SAN JOSE
400976 - Purchaser ID: 887 Contract: 4 Version: 46 EOC Number: 29
400977 - January 1, 2004 through December 31, 2004
400979 - ..
400980 - Special Note about Services Associated with Clinical Trials
400982 - ..
400983 - You should ask the clinical trial provider if the clinical
400984 - trial qualifies for Medicare payments and what Medicare
400985 - coinsurance and other out-of-pocket expenses you will have
400986 - to pay for related Services. ref DIT 1 004G
400988 - ..
400989 - Kaiser guidance for customers to ask clinical trial provider about
400990 - coinsurance and other costs, conflicts with a letter today reporting
400991 - the clinical trial director doesn't know anything about billings,
400992 - despite having investigated a lot of time to find out if Millie would
400993 - have to pay any out-of-pocket expenses, see below, ref SDS 0 I49K,
400994 - confirming understandings from meeting with Bob at UCSF on 070830.
400995 - ref SDS 12 WU5N
400996 -
400997 - [...in another record today, Kaiser's guidance
400998 - received from the Oncology Department says patients
400999 - who self-refer for treatment in clinical trials are
401000 - charged coinsurance, but do not say how much.
401001 - ref SDS 15 WD3Y
401003 - ..
401004 - Millie's letter to UCSF and Kaiser continues...
401005 -
401006 - 4. These sources support the record in this case that the clinical
401007 - trial provider asked the referring doctor about payment of
401008 - expenses and was notified that Kaiser would pay for expenses
401009 - not covered by the clinical trial. [reported on 061230,
401010 - ref SDS 2 3X6K, At no time was I informed that charges were
401011 - accumulating for services at UCSF beyond insurance premiums.
401012 - Specifically I was not told of coinsurance charges, and was
401013 - told there is no copayment charge on clinical trials. [see
401014 - report on 070130, ref SDS 5 KS6M and ref SDS 5 LC60,
401015 - ref DIT 1 WM85
401017 - ..
401018 - Clinical trial director confirms in a letter received later today that
401019 - Millie was not informed of coinsurance charges because UCSF did not
401020 - know of any grounds for billing the customer, and further notes this
401021 - case is very complicated. see below, ref SDS 0 UK5M
401022 -
401023 - [...in another record today, Arlette submitted Kaiser
401024 - internal guidance on clinical trials for Senior Advantage
401025 - beneficieries, ref SDS 15 WC5S, who are charged
401026 - coinsurance, ref SDS 15 WD3Y; no amount is reported.
401027 - ref SDS 15 WD3Y
401029 - ..
401030 - [On 070909 letter to Kaiser and to UCSF notifying charges
401031 - for coinsurance conflict with agreement on 061230 that
401032 - Kaiser would pay any costs not covered by clinical trial,
401033 - ref SDS 17 6O4U, and submit interim payment of copayments
401034 - for doctor visits, pending submission of justification for
401035 - charges when UCSF represents cost of doctor visits are paid
401036 - by the clinical trial. ref SDS 17 XM4F
401038 - ..
401039 - [On 070917 UCSF revised claim reduced to $1,500, annualized
401040 - to about $2K per year, ref SDS 18 WO4O, which more than
401041 - doubles copayment costs typically incurred for the work
401042 - involved. ref SDS 18 G68H
401044 - ..
401045 - If medical professionals don't know about coinsurance charges, this
401046 - indicates UCSF was satisfied that Kaiser would pay any costs not
401047 - covered by the trial. ref SDS 0 XK4Y
401049 - ..
401050 - Millie's letter to UCSF and Kaiser continues...
401051 -
401052 - 5. Bob indicated during the meeting on August 30th, that the
401053 - doctor was unable to notify the customer in this case about
401054 - charges, because nobody knows the amount until after UCSF
401055 - negotiates with Medicare and receives final payment for
401056 - billings. ref SDS 12 WU5N This appears somewhat conflicting
401057 - with the consistent pattern of charges in UCSF documentation,
401058 - shown below extracting coinsurance amounts. ref SDS 0 RD6I,
401059 - ref DIT 1 WM92
401060 -
401061 - [On 070917 UCSF revised claim reduced to $1,500, annualized
401062 - to about $2K per year, ref SDS 18 WO4O, which more than
401063 - doubles copayment costs typically incurred for the work
401064 - involved. ref SDS 18 G68H
401066 - ..
401067 - Millie's letter to UCSF and Kaiser continues...
401068 -
401069 - 6. My general understanding at this time is that UCSF seeks
401070 - recovery of "coinsurance" each time I visit with Doctor Rugo,
401071 - and/or her team for examination. Recently, the doctor
401072 - determined care has improved my condition sufficiently to
401073 - reduce meetings from twice to now just once a month.
401074 - ref DIT 1 WM96
401076 - ..
401077 - 7. Bob further indicated on August 30th that accounts in the UCSF
401078 - spreadsheet showing charges of $101 are for doctor visits
401079 - billed to Medicare. There was agreement to make interim
401080 - payment for doctor visits. ref SDS 12 V373 At this time the
401081 - amounts UCSF seeks to recover from me appear to vary from
401082 - $22.26 to 27.88. The basis for variable charges to the
401083 - customer of a fixed charge to Medicare has not been explained
401084 - by UCSF. [noted during the meeting at UCSF on 070830.
401085 - ref SDS 12 VT5W], ref DIT 1 WM97
401087 - ..
401088 - Implements Millie's letter on 070904 agreeing to make interim payment
401089 - of coinsurance and requesting UCSF to submit justification for this
401090 - charge. ref SDS 14 6R4W interim agreement to make partial payment on
401091 - coinsurance subject to justification by UCSF, and reimbursement upon
401092 - payment by Kaiser for Millie's care at UCSF. ref SDS 14 6R4W
401094 - ..
401095 - Millie's letter to UCSF continues...
401096 -
401097 - 8. Accordingly, as requested by Bob, today I will submit a
401098 - check to the UCSF Admissions Office on the ground floor at 1600
401099 - Divisadero, ref SDS 14 6R4W, and in the amount of $312.08 [...
401100 - subject to justification noted in Millie's letter on September
401101 - 4, 2007, ref SDS 14 6R4W...]. This amount was derived by
401102 - adding amounts that Bob checked with an ink pen on a
401103 - spreadsheet he prepared dated August 27, 2007 with the title...
401104 - ref DIT 1 WM98 [...and further subject to refund on payment to
401105 - UCSF by Kaiser for Millie's care, agreed with UCSF during
401106 - meeting on 070830 0807. ref SDS 12 FT6K and in particular -
401107 - ref SDS 12 QH6J...]
401109 - ..
401112 - Summary of Facility Accounts
401113 -
401114 - Doctor Visit Account Total Coinsurance
401115 -
401116 - 30-Jan-07 12571560 101.00 27.88
401117 - 01-Feb-07 12575738 101.00 22.26
401118 - 08-Feb-07 12588855 101.00 27.88
401119 - 01-Mar-07 12575761 101.00 22.26
401120 - 15-Mar-07 12720616 101.00 27.88
401121 - 29-Mar-07 12762558 101.00 27.88
401122 - 19-Apr-07 12880922 101.00 27.88
401123 - 26-Apr-07 12762597 101.00 22.26
401124 - 10-May-07 12762609 101.00 27.88
401125 - 24-May-07 12762615 101.00 27.88
401126 - 07-Jun-07 12997853 101.00 27.88
401127 - 21-Jun-07 12997859 101.00 22.26
401128 -
401129 - $312.08
401131 - ..
401132 - 9. I will be out of town for the next few weeks. Please submit
401133 - the amount I owe for meetings with Doctor Rugo since June 21,
401134 - so that I can bring the account up to date when I return. I
401135 - would like to make copayments on a pay-as-you-go basis at the
401136 - time services are performed, hopefully by credit card.
401137 - ref DIT 1 WM6F
401138 -
401139 - [On 070917 received revised UCSF billing spreadsheet
401140 - reducing claim by $8K down to $1,194.52. ref SDS 18
401141 - WP5I
401143 - ..
401144 - [On 070917 Medicare statute Title 42 section 419.40
401145 - explains coinsurance minimum 20% for participation in
401146 - clinical trials to advance medical science. ref SDS 18
401147 - 4Q3I
401149 - ..
401150 - [On 070927 Senior Advantage EOC section 2 Kaiser must
401151 - pay for prescribed care; relieves Millie of charges for
401152 - coinsurance under section 7, ref SDS 20 WS6M, and
401153 - established by 16 grounds, ref SDS 20 WU6M, aligns with
401154 - agreement in correspondence between Kaiser and UCSF on
401155 - 061230 for Kaiser to pay any costs not covered by the
401156 - clinical trial. ref SDS 2 3X6K
401158 - ..
401159 - [On 071128 Kaiser Appeals Committee approved payment
401160 - for Millie's care on referral to UCSF. ref SDS 30 JZ5R
401161 -
401162 -
401163 -
401164 -
401165 -
4012 -
SUBJECTS
Commend Excellent Professional Care UCSF Medical Center Love Working
6003 -
600401 - ..
600402 - Commend UCSF Doctor Rugo Infusion Staff Excellent Care
600403 -
600405 - ..
600406 - 10. I only add that everyone should understand that I love working
600407 - with Doctor Rugo, Brigid, Jackie, Catherine, Diane, Flora,
600408 - Nola. Everyone is competent, professional, and personable,
600409 - similar to my experience at Kaiser. ref DIT 1 WM6M
600410 -
600411 -
600412 -
600413 -
6005 -
SUBJECTS
Payment Doctor UCSF Knows Nothing Medicare Coinsurance Invested Hour
9203 -
9204 - 1127
920501 - ..
920502 - Complex Issues Requird Focused Review Patient History
920503 - Clinical Trial Provider Did Not Know Coinsurance Cost
920504 - Coinsurance Cost Clinical Trials Not Known by Kaiser or UCSF
920505 -
920506 - Millie received ref DRT 1 0001 from Doctor Rugo at UCSF responding to
920507 - Millie's letter this morning, ref DIT 1 0001, per above, and also to
920508 - the letter, ref DIP 2 0001, submitted to UCSF on 070904 that requested
920509 - support from the doctor. ref SDS 14 6Q7Y Copies went to Jackie, the
920510 - primary care physician at Kaiser, and Bob Schwartz in accounting at
920511 - UCSF. ref DRT 1 00W3
920512 -
920513 - 1. Please know that I have nothing to do with billing. As you
920514 - know, we spent hours trying to get help from Kaiser in
920515 - determining coverage, and all we ever found out was that
920516 - medicare would be responsible - but we never knew for how much.
920517 - I never had any more information than this, and of course this
920518 - is very complicated. ref DRT 1 0001
920520 - ..
920521 - Doctor Rugo's assessment that this case is very complicated aligns
920522 - with Bob Schwartz's analysis on 070823, ref SDS 10 RV6U, and so
920523 - requires careful review of case studies to understand causation, shown
920524 - in the record on 070830. ref SDS 12 LQ5I
920526 - ..
920527 - [On 070926 Karen at Kaiser assigned by primary care
920528 - physician to facilitate solution of clinical trial
920529 - payment issues notes Millie's case is very complex,
920530 - which requires careful support for team care doctor
920531 - patient partnership. ref SDS 19 QY5I
920533 - ..
920534 - [On 071010 UCSF tells patient to contact Medicare for
920535 - explanation of UCSF billings. ref SDS 22 OH7R
920537 - ..
920538 - [On 071011 UCSF accounting department refuses to explain
920539 - charges; Millie asks Doctor Rugo facilitate communications
920540 - to get the total amount UCSF claims Millie owes for
920541 - clinical trial services. ref SDS 23 K64W
920543 - ..
920544 - [On 071015 Millie has tried contacting Medicare for
920545 - explanation of UCSF invoices and was not successful,
920546 - similar to Doctor Rugo's experience in January. ref SDS 24
920547 - KH5Q
920549 - ..
920550 - [On 071018 0800 Doctor Rugo reports investigation indicates
920551 - Kaiser "cut Millie loose" to avoid responsibility for
920552 - providing standard of care which Kaiser ordered on referral
920553 - to UCSF. ref SDS 25 W23I
920555 - ..
920556 - Seems to confirm Millie was not notified of extra charges for
920557 - coinsurance, ref SDS 12 T247, and that this would be $10K, which is
920558 - 56% of the amount Medicare pays for treatment in the clinical trial,
920559 - reviewed on 070830. ref SDS 12 WP5I
920560 -
920561 - [...in another record today, Arlette submitted Kaiser
920562 - internal guidance on clinical trials for Senior Advantage
920563 - beneficieries, ref SDS 15 WC5S, who are charged
920564 - coinsurance; no amount is reported. ref SDS 15 WD3Y
920566 - ..
920567 - Case study on 070130 reports efforts by UCSF and Kaiser to start
920568 - Millie's treatment, ref SDS 6 2X6L, and aligns with the study on
920569 - 070830 from meeting with UCSF. ref SDS 12 LQ5I
920571 - ..
920572 - Doctor Rugo's letter continues...
920573 -
920574 - I would involve Kaiser in this discussion though, as you have
920575 - active insurance through them, and they referred you for
920576 - participation in the trial. I think the medicare coverage
920577 - rules here are very muddy, and relate to your relationship with
920578 - Kaiser. But I am no expert here, and really know nothing about
920579 - billing and coverage in this situation. ref DRT 1 0W6G
920581 - ..
920582 - UCSF confirms that Kaiser made the referral, as noted in Kaiser's
920583 - letter relating correspondence with UCSF on 061230, ref SDS 2 3X6K,
920584 - and confirmed by primary care physician on 070119. ref SDS 4 4R4M
920585 -
920586 - [On 070907 Doctor Johnson, primary care physician at
920587 - Kaiser, also reports not knowing anything about billings at
920588 - Kaiser. ref SDS 16 XH5H
920590 - ..
920591 - [On 070909 letter to Kaiser and to UCSF notifying charges
920592 - for coinsurance conflict with agreement on 061230 that
920593 - Kaiser would pay any costs not covered by clinical trial,
920594 - ref SDS 17 6O4U, and submit interim payment of copayments
920595 - for doctor visits, pending submission of justification for
920596 - charges when UCSF represents cost of doctor visits are paid
920597 - by the clinical trial. ref SDS 17 XM4F
920599 - ..
920600 - [On 070917 UCSF revised claim reduced to $1,500, annualized
920601 - to about $2K per year, ref SDS 18 WO4O, which more than
920602 - doubles copayment costs typically incurred for work
920603 - involved. ref SDS 18 G68H
920605 - ..
920606 - [On 071006 UCSF submits additional billings increasing
920607 - charges to about $20K per year; UCSF's actual claim very
920608 - difficult to determine. ref SDS 21 PRWW
920610 - ..
920611 - [On 071006 CMS made referral to Paula in Kaiser Member
920612 - Relations group; Paula seems very capable addressing
920613 - complex issues in this case. ref SDS 21 Q998
920615 - ..
920616 - [On 071011 Millie requests UCSF explain confusing billings,
920617 - citing Doctor Rugo's comment that requirements are "very
920618 - muddy." ref SDS 23 K65V
920620 - ..
920621 - [On 071018 0800 Doctor Rugo reports investigation indicates
920622 - Kaiser "cut Millie loose" to avoid responsibility for
920623 - providing standard of care which Kaiser ordered on referral
920624 - to UCSF. ref SDS 25 W23I
920626 - ..
920627 - [On 071026 UCSF responds, ref SDS 26 K49J, and demands
920628 - payment of its claim against Millie within 1 week.
920629 - ref SDS 26 SU5V
920631 - ..
920632 - [On 071027 patient requests meeting so UCSF can present
920633 - claim, and explain charges. ref SDS 27 CG6H
920635 - ..
920636 - [On 071029 UCSF refuses to meet; claims suffering from
920637 - delay "stringing out payments. ref SDS 28 6N6K
920639 - ..
920640 - [On 071031 UCSF notice treatment for cancer ordered by
920641 - Kaiser will be terminated, ref SDS 29 KM8J; further notice
920642 - UCSF making referral to collection agency for payment of
920643 - $202.65 on Kaiser referral. ref SDS 29 KK4I
920645 - ..
920646 - [On 071128 Kaiser Appeals Committee approved payment for
920647 - Millie's care on referral to UCSF. ref SDS 30 JZ5R
920649 - ..
920650 - Doctor Rugo's letter continues...
920651 -
920652 - 2. As we discussed initially, there was some risk involved as
920653 - there is no way to get pre-approval from medicare. ref DRT 1
920654 - BW6N
920656 - ..
920657 - 3. Bob, any thoughts on this and who the Buck's could contact
920658 - through Kaiser? ref DRT 1 MW7H
920660 - ..
920661 - If medical professionals don't know about extra charges, this supports
920662 - Millie's reliance on Kaiser paying any costs not covered by the trial,
920663 - as agreed between Kaiser and UCSF in correspondence on 061230.
920664 - ref SDS 2 3X6K
920665 -
920666 -
920667 -
920668 -
920669 -
920670 -
920671 -
920672 -
920673 -
920674 -
920675 -
920676 -
920677 -
9207 -