CONTACTS 
0201 - CMS Region 9
020101 - Ms. Lee Faleafine; Customer Representative
020103 - Division of Medicare Health Plans Operations

SUBJECTS
Kaiser Payment Millie's Treatment Continuing Care Referral UCSF Clin

3403 -
3403 -    ..
3404 - Summary/Objective
3405 -
340501 - Follow up ref SDS 18 0000. ref SDS 15 0000.
340502 -
340503 -
340504 -
340505 -
340506 -
340507 -
340508 -
340510 -  ..
3406 -
3407 -
3408 - Progress
3409 -
340901 - Submitted letter, ref DIT 1 0001, to CMS following up Lee's request on
340902 - 070927, ref SDS 18 VG8M, for an explanation of UCSF billing and
340903 - payment issues surrounding Kaiser's referral for Millie's treatment,
340904 - and attaching the letters to Karen referred by the primary cary
340905 - physician, and which provide background for CMS review...
340906 -
340907 -    1.  Last week on September 27, we received a call from Cathy
340908 -        Windfield Jones with CMS.  She suggested calling your office at
340909 -        415 744 3617 to assist in resolving a payment issue with
340910 -        Kaiser. ref SDS 18 KA71  Millie has been treated for breast
340911 -        cancer at Kaiser in Walnut Creek, CA since 2002, and was
340912 -        referred for treatment at UCSF on a clinical trial beginning on
340913 -        070130 (2007, January, 30). ref SDS 4 0001, ref DIT 1 0001
340914 -
340915 -            [On 071003 Jullin called with CMS in San Francisco, and is
340916 -            reviewing the case based on this letter. ref SDS 20 7G5G
340918 -         ..
340919 -    2.  Though not presented when the doctor made the referral on
340920 -        070105, ref SDS 2 PK7L, in August Millie began getting a lot of
340921 -        invoices, now over 100, from UCSF backdated for treatment in
340922 -        January that total over $4K for treatments prescribed by Kaiser
340923 -        and performed by UCSF, shown on 070823. ref SDS 6 1Y9N
340924 -        Annualized amount is $10K [shown by review during meeting at
340925 -        UCSF on 070830], nearly 10 times the amount of insurance
340926 -        premiums. ref SDS 8 W05N, ref DIT 1 NN6K
340928 -         ..
340929 -    3.  I met with UCSF's accounting rep, Bob Schwartz, on 070830.  Bob
340930 -        indicated UCSF does not know the basis for their charges,
340931 -        except that Kaiser's Medicare unit calculates the amount UCSF
340932 -        bills Millie, ref SDS 8 WU5N, and justification is based on
340933 -        Kaiser's determination that Millie can "self-refer" for
340934 -        participation in a clinical trial. ref SDS 8 NQ3F, ref DIT 1
340935 -        1I7J
340937 -         ..
340938 -    4.  Our question to CMS is whether Medicare support for patients to
340939 -        "self-refer" for treatment in clinical trials that advance
340940 -        science, prohibits Kaiser from referring patients for treatment
340941 -        in clinical trials [as set out on 070830, ref SDS 8 NQ3F, and],
340942 -        as Kaiser has been doing in this case since 2002, shown by the
340943 -        study on 070830. ref SDS 8 LQ5I, ref DIT 1 1I8J
340945 -             ..
340946 -            [On 071003 Jullin called with CMS in San Francisco, and is
340947 -            reviewing the case based on this letter. ref SDS 20 7G5G
340949 -             ..
340950 -            [On 071003 Jim Mayhew will investigate CMS policy.
340951 -            ref SDS 20 0E4K
340953 -             ..
340954 -            [On 071004 submitted letter to CMS dated 071002 (today),
340955 -            ref SDS 0 KA5J, to Jim Mayhew for policy review.
340956 -            ref SDS 21 KA5J
340958 -             ..
340959 -            [On 071006 Paula called Kaiser MCRC received fax from CMS
340960 -            with letter to Lee on 071002, ref SDS 22 Z87L, suggesting
340961 -            Jullin sent the fax.
340963 -             ..
340964 -            [On 071009 Jullin has submitted this question to CMS
340965 -            research department for analysis, ref SDS 23 R66K; Jullin
340966 -            does not report sending the letter to CMS to Paula at
340967 -            Kaiser. ref SDS 23 LT7J
340969 -             ..
340970 -            [On 071010 Kaiser letter dated 071006 cites Millie's appeal
340971 -            dated 071001, which later turned out to be a letter sent to
340972 -            CMS dated 071002, and which CMS sent to Kaiser. ref SDS 24
340973 -            TH8L
340975 -             ..
340976 -            [On 071012 research on clinical trial legal authority.
340977 -            ref SDS 25 VV5M
340979 -             ..
340980 -            [On 071029 Jim Mayhew with CMS HQ in Maryland or Virginia
340981 -            reported he did not receive the letter dated today, 071002,
340982 -            ref SDS 0 KA5J, due to email problems at CMS, ref SDS 26
340983 -            6N8R, resubmitted letter during call; Jim reported he
340984 -            received it; after discussion, Jim agreed to assign someone
340985 -            to make a review independent from CMS in San Francisco.
340986 -            ref SDS 26 0Z5J
340988 -             ..
340989 -            [On 071029 Jullin advised CMS preparing written response to
340990 -            letter to CMS dated 071002 on statutory autority for
340991 -            payment responsibility when patient self-refers for
340992 -            treatment in a clinical trial, and distinguished from when
340993 -            the doctor prescribes treatment in a clinical trial.
340994 -            ref SDS 26 WP7O
340996 -             ..
340997 -            [On 071030 Paula confirmed reference to letter dated 071001
340998 -            in Kaiser letter dated 071006 was a mistake, and that she
340999 -            intended to reference the letter dated 071002 to CMS as the
341000 -            basis of an appeal which Kaiser formulated on Millie's
341001 -            behalf after Jullin faxed the letter to Kaiser. ref SDS 27
341002 -            V26V
341003 -
341004 -
341006 -  ..
341007 - Included attached letters....
341008 -
341009 -        1.  Patient letter to Kaiser ATTN:  Karen Kupetz
341010 -            Dated:  October 1, 2007 2143
341011 -            Subject;  Patient Millie UCSF MRN......; Kaiser MRN......
341012 -            ref DIP 7 0001.................... ref SDS 19 QY5I
341014 -             ..
341015 -        2.  Patient letter to Kaiser ATTN:  Karen Kupetz
341016 -            Dated:  September 26, 2007 1701
341017 -            Subject;  Patient Millie UCSF MRN......; Kaiser MRN......
341018 -            ref DIP 6 0001.................... ref SDS 17 4I5G
341020 -             ..
341021 -        3.  Kaiser Karen Kupetz to Patient
341022 -            Dated September 26, 2007 1005
341023 -            Subject;  Patient Millie UCSF MRN......; Kaiser MRN......
341024 -            ref DRP 4 0001....................... ref SDS 17 QY5I
341025 -
341026 -
341027 -
341028 -
341029 -
3411 -

SUBJECTS
Clinical Trials Coinsurance Medicare Kaiser Senior Advantage Transfe

7503 -
7504 - 1702
750501 -  ..
750502 - CMS Millie First Patient New Medicare Regulations Clinical Trials
750503 -
750504 -
750505 - Mark Manfredi.....  415 744 3614.
750507 -  ..
750508 - Mark called on 071002 to follow up a call he received from Catherine a
750509 - few weeks ago, who was contacted on 070917 for clarification of CMS
750510 - requirements. ref SDS 13 SY6K
750512 -  ..
750513 - Mark seemed to indicate that Millie is the first patient processed
750514 - under new Medicare rules for clinical trials.  This aligns with
750515 - Arlette's report on 070829 that Millie is the first referral Kaiser
750516 - Oncology in Walnut Creek has made under new Medicare rules.
750517 - ref SDS 7 EG4N  Doctor Rugo commented on "muddy" Medicare rules in a
750518 - letter on 070906. ref SDS 10 UK5M  The primary care physician at Kaiser
750519 - described confusing Medicare requirements, in a letter on 070119.
750520 - ref SDS 3 LW9N  On 070921 the doctor noted challenges of frequently
750521 - changing Medicare rules. ref SDS 15 QY96
750523 -  ..
750524 - Mark feels the letter Lee Faleafine requested on 070927, ref SDS 18
750525 - VG8M, and which was submitted to Lee today, per above, ref SDS 0 KA5J,
750526 - should be reviewed by
750527 -
750528 -                  Jullin Kwok....... 415 744 3572.
750529 -
750530 - ...who manages the Medicare contract for the Kaiser Senior Advantage
750531 - "managed care" account.
750533 -  ..
750534 - Mark explained that Jullin is out of the office.  He will ask her to
750535 - follow up tomorrow.
750536 -
750537 -            [On 071003 Jullin Kwok called and plans to make thorough
750538 -            review of payment dispute between Kaiser and UCSF in
750539 -            Millie's case, ref SDS 20 7G5G; describes complex case.
750540 -            ref SDS 20 BZ40
750542 -             ..
750543 -            [On 071006 Paula called Kaiser MCRC received fax from CMS
750544 -            with letter to Lee on 071002, ref SDS 22 Z87L, suggesting
750545 -            Jullin sent the fax.
750547 -  ..
750548 - Mark further suggested that Millie review a CMS and/or Medicare
750549 - publication...
750550 -
750551 -      Your rights and protections...
750553 -         ..
750554 -        http://search.live.com/results.aspx?q=medicare+publications&FORM=SSRE2
750556 -  ..
750557 - He said to let him know if we need help accessing the document on the
750558 - Internet.
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7506 -