CONTACTS 

SUBJECTS
Medicare Coinsurance 20% Patients  Slf-refer Clinical Trials Kaiser

5103 -
5103 -    ..
5104 - Summary/Objective
5105 -
510501 - Follow up ref SDS 9 0000. ref SDS 7 0000.
510502 -
510503 -
510504 -
510505 -
510506 -
510507 -
510509 -  ..
5106 -
5107 -
5108 - Progress
5109 -
510901 - Clinical Trials Managed Care Provider Doctor Makes Referral
510902 -
510903 - Submitted letter, ref DIT 1 0001, to CMS confirming discusison with
510904 - James yesterday on 071003. ref SDS 9 KA5J
510905 -
510906 -    1.  Following our telecon yesterday, this issue arises from a
510907 -        patient enrolled in Kaiser's Senior Advantage program since
510908 -        approximately 2004, and with Kaiser for 20+ years.  Kaiser
510909 -        describes Senior Advantage as shown in the record on 070927
510910 -        (September 27, 2007), and with comments showing the plain
510911 -        language is not dispositive. ref SDS 7 1F6L, ref DIT 1 0001
510912 -
510913 -            [On 071029 Jim reported he did not receive the letter due
510914 -            to email problems at CMS, ref SDS 10 6N8R, resubmitted
510915 -            letter during call; Jim reported he received it; after
510916 -            discussion, Jim agreed to assign someone to make a review.
510917 -            ref SDS 10 0Z5J
510919 -             ..
510920 -            [On 071029 letter to CMS confirms discussion with Jim that
510921 -            he is following up with review, and submitted 16 issues in
510922 -            this case. ref SDS 10 RN7X
510924 -         ..
510925 -    2.  (Note:  this is a knowledge management environment; click on
510926 -        subsidiary links only when you want to know more about an
510927 -        issue, e.g., a case study), ref DIT 1 DK6I
510929 -         ..
510930 -    3.  On 061230 (December 30, 2006), Kaiser made arrangements for
510931 -        UCSF to treat a patient in a clinical trial determined by
510932 -        Kaiser to be the best course of care.  The patient made no
510933 -        self-referral, but merely followed the doctor's orders.  Kaiser
510934 -        agreed to pay UCSF any costs not covered by the clinical trial.
510935 -        ref SDS 1 3X6K, ref DIT 1 DK6L
510937 -         ..
510938 -    4.  A policy question is whether Kaiser is prevented from
510939 -        prescribing and paying for treatments Kaiser determines
510940 -        medically essential and which it cannot otherwise provide?
510941 -        Does CMS and Medicare recognize distinctions between physician
510942 -        referral and patient "self-referral"? ref DIT 1 DK7H
510944 -         ..
510945 -    5.  Subsidiary question is whether the patient can rely on
510946 -        authority of the doctor to prescribe treatments based on past
510947 -        pattern and practice, or may Kaiser lead a patient into
510948 -        expensive treatment without notice, and then 6 months later
510949 -        start demanding payments? ref DIT 1 DK7O
510951 -         ..
510952 -    6.  Not sure these issues are very elegantly presented.  It is a
510953 -        little late and we have to leave for San Francisco in a few
510954 -        hours for Millie's weekly treatments at UCSF. ref DIT 1 DK8L
510956 -         ..
510957 -    7.  The record on 070830 provides context with several case studies
510958 -        on patient history that may be helpful (this is a bit complex,
510959 -        showing for example mind boggling invoices). ref SDS 3 0000,
510960 -        ref DIT 1 OE9G
510962 -         ..
510963 -    8.  The most glaring question is how a patient sent for treatment
510964 -        with assurances of no cost can wind up with a bill for
510965 -        "coinsurance" 8 months later for $10K per year at 56% of
510966 -        amounts approved by Medicare? ref DIT 1 DK9L
510968 -         ..
510969 -    9.  Millie's specific concerns on coinsurance are listed on 070830.
510970 -        ref SDS 3 T94O, ref DIT 1 ML4J
510972 -         ..
510973 -   10.  There are few lessons learned that may be helpful. ref SDS 5
510974 -        8X8H, ref DIT 1 YO5F
510976 -         ..
510977 -   11.  Thanks for taking a look.  Don't get lost in links.  If the
510978 -        case seems interesting, please call 925 680 8947 to discuss
510979 -        your ideas. ref DIT 1 DK4P
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5110 -