CONTACTS 

SUBJECTS
Payment Clinical Trial Kaiser Obligation  Kiser Referral for Treatme
Payment Clinical Trial Kaiser Obligation Kaiser Referral for Treatme

4204 -
4204 -    ..
4205 - Summary/Objective
4206 -
420601 - Follow up ref SDS 10 0000. ref SDS 8 0000.
420602 -
420603 -
420604 -
420605 -
420607 -  ..
4207 -
4208 -
4209 - Progress
4210 -
421001 - Submitted letter, ref DIT 1 0001, to doctors at UCSF and Kaiser
421002 - collaborating on Millie's care, and responding to letter from Doctor
421003 - Rugo on 070906, ref SDS 8 I49K, and from primary care physician at
421004 - Kaiser on 070907. ref SDS 10 XH5H
421006 -         ..
421007 -    1.  Thanks for collaborating to support UCSF accounting, requested
421008 -        in Millie's letter on September 4th, ref SDS 7 6Q7Y, cited in
421009 -        her letter on the 6th, ref SDS 8 KM3K, and following up the
421010 -        letter to Jackie on Aug 31, with a copy to Bob Schwartz in UCSF
421011 -        accounting. ref SDS 6 G15I, ref DIT 1 0001
421012 -
421013 -            [On 070917 Millie received UCSF letter dated 070912 that
421014 -            reduces the amount of UCSF claim from $4,300 to $1,500.
421015 -            ref SDS 11 595P
421017 -         ..
421018 -    2.  Doctor Rugo confirms in a letter dated Sep 6th, that UCSF
421019 -        investigated payment issues prior to Millie starting treatment
421020 -        at UCSF on Jan 30th. ref SDS 8 I49K  Similarly, [the primary
421021 -        care physician at Kaiser] indicates in a letter on Sep 7th
421022 -        having investigated payment requirements. ref SDS 10 XH5H
421023 -        Millie was never notified she would owe UCSF any payment for
421024 -        treatment in the clinical trial. [shown in Millie's letter to
421025 -        the doctors on 070906, ref SDS 8 KC8S, restating notice in
421026 -        Millie's letter on 070904. ref SDS 7 6Q8W], ref DIT 1 116J
421028 -         ..
421029 -    3.  As noted in the letter to Jackie on August 31, Millie met
421030 -        briefly with [the primary care physician's] assistant, Arlette,
421031 -        on August 29th at Kaiser in Walnut Creek.  Arlette indicated
421032 -        surprise that Millie would be getting billed for clinical trial
421033 -        expenses, and promised to investigate. ref SDS 4 EF6J  In her
421034 -        letter on August 9, 2006, she related extensive experience in
421035 -        the Oncology Department at Kaiser in Walnut Creek making
421036 -        referrals to UCSF, and other providers. ref SDS 1 NT9X,
421037 -        ref DIT 1 1172
421039 -         ..
421040 -    4.  As usual, Arlette followed up on her promise to investigate why
421041 -        Millie suddenly got a lot of invoices (now over 40) from UCSF
421042 -        in August, when she was told in January that she would not owe
421043 -        any payment for participating in the UCSF clinical trial.  On
421044 -        September 6th, last week Thursday, ref SDS 9 3L8G, Millie
421045 -        received a letter from Arlette transmitting a document with the
421046 -        title:, ref DIT 1 1183
421048 -         ..
421049 -    5.  "Medicare Coverage Policy Clinical Trials"
421050 -
421051 -        The document is undated, and says "For internal use only,"
421052 -        however it aligns with documents received from Barbara in the
421053 -        Customer Service department at Kaiser in Walnut Creek received
421054 -        during a meeting, also, on August 29th. ref SDS 4 RA85  Both
421055 -        sources state expressly that Medicare pays costs of "routine
421056 -        care" for clinical trials. [reported 070906] ref SDS 9 WC6S
421057 -        You don't have to be a billing expert to appreciate the clarity
421058 -        of that representation. ref DIT 1 RK4W
421060 -         ..
421061 -    6.  At this time, the only items of cost in UCSF invoices which can
421062 -        be identified are for "coinsurance."  Millie disputes this
421063 -        charge for reasons presented in the letter to UCSF on August
421064 -        31, 2007. ref SDS 6 PX5R  On Sep 6th, Millie made interim
421065 -        payment for coinsurance, ref SDS 8 EB3P, based on Bob marking
421066 -        up his spreadsheet during a meeting at UCSF the day before on
421067 -        August 30th. ref SDS 5 W141  Millie has requested justification
421068 -        for these charges in the face of unequivocal representations
421069 -        that the clinical trial paid for office visits. [Millie's
421070 -        letter to UCSF and Kaiser dated 070904. ref SDS 7 6R4W],
421071 -        ref DIT 1 1196
421072 -
421073 -            [On 070917 Millie received UCSF letter dated 070912 that
421074 -            cites CMS section 69.9 to justify charges for coinsurance.
421075 -            ref SDS 11 596Q
421077 -         ..
421078 -    7.  Aside from "co-insurance," it is unclear in the record what
421079 -        further costs UCSF seeks to recover from the patient above and
421080 -        beyond costs of "routine care."  There is nothing in the record
421081 -        showing Doctor Rugo has ordered anything other than "routine
421082 -        care."  Everything Millie has done in connection with getting
421083 -        treatment at UCSF has implemented written instructions from the
421084 -        doctor, including getting CT tests at Kaiser. ref DIT 1 1146
421086 -         ..
421087 -    8.  Accordingly, there is no evidence showing Millie owes anything
421088 -        further to UCSF. ref DIT 1 1155
421090 -            ..
421091 -           [On 070917 UCSF revised claim reduced to $1,500, annualized
421092 -           to about $2K per year, ref SDS 11 WO4O, which more than
421093 -           doubles copayment costs typically incurred for the work
421094 -           involved. ref SDS 11 G68H
421096 -            ..
421097 -           [On 070924 UCSF letter cites Millie's insurance coverage
421098 -           with Kaiser Senior Advantage. ref SDS 12 EZ5J
421100 -            ..
421101 -           [On 070927 Millie found documentation from Kaiser that
421102 -           describes coinsurance for "self-referral" to participate in
421103 -           clinical trials for medical research. ref SDS 13 1G4O
421104 -
421106 -         ..
421107 -        Patient Entitled to Know Charges Prior to Treatment
421108 -
421109 -
421110 -    9.  UCSF accounting should demand payment owed for "routine care."
421111 -        The medical team can support this effort with a letter to the
421112 -        Accounting department stating that services in Millie's case
421113 -        are for "routine care."  If recovery is denied, then Doctor
421114 -        Rugo should be notified what work is being performed that is
421115 -        not "routine care," so that the patient can decide in advance
421116 -        whether to pay for non-routine care, what ever that turns out
421117 -        to be.  If constructive discussions occur with Medicare and
421118 -        Kaiser, and you need support on patient history, please let me
421119 -        know. ref DIT 1 115G
421121 -         ..
421122 -   10.  Let's try to get some understandings in place before Mil
421123 -        returns for treatment on Sep 20th.  While nobody seems to an
421124 -        "expert" in billings when it comes to Medicare, including the
421125 -        folks at Medicare, collaborating on a solution in this case may
421126 -        yield experience to guide future work, especially if we can
421127 -        tease out of the system the authority for allocating charges.
421128 -        What specific language is being relied upon to govern the work?
421129 -        ref DIT 1 116H
421130 -
421131 -           [On 070917 UCSF revised claim reduced to $1,500, annualized
421132 -           to about $2K per year, ref SDS 11 WO4O, which more than
421133 -           doubles copayment costs typically incurred for the work
421134 -           involved. ref SDS 11 G68H
421136 -            ..
421137 -           [On 070924 UCSF letter cites Millie's insurance coverage
421138 -           with Kaiser Senior Advantage. ref SDS 12 EZ5J
421140 -            ..
421141 -           [On 070927 Millie found documentation from Kaiser that
421142 -           describes coinsurance for "self-referral" to participate in
421143 -           clinical trials for medical research. ref SDS 13 1G4O
421145 -         ..
421146 -   11.  Thanks again to Doctor Rugo, and [the primary care physician at
421147 -        Kaiser] for taking time to consider this matter, and to Bob
421148 -        Schwartz for crunching the numbers. ref DIT 1 123G
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