CONTACTS
SUBJECTS
CMS Referral Clinical Trial Referral Coinsurance Payment Dispute UCS
6503 -
6503 - ..
6504 - Summary/Objective
6505 -
650501 - Follow up ref SDS 26 0000. ref SDS 25 0000.
650502 -
650503 - Paula was very constructive learning patient history for application
650504 - of Kaiser policy and work practices. We made progress identifying
650505 - issues toward paying for Millie's treatment at UCSF. Paula discussed
650506 - recommending Kaiser pay for the work as a straight referral to reflect
650507 - patient history. She cautioned that a Kaiser panel may disagree.
650508 - ref SDS 0 TL98 Paula plans to investigate several issues. ref SDS 0
650509 - 453G The basis of UCSF billings present continuing problems.
650510 - ref SDS 0 454M Paula understands Millie's objectives are to make
650511 - equitable payment that supports a continuing relationship with Kaiser
650512 - and UCSF for her treatments which have been very effective.
650513 - ref SDS 0 Q963
650514 -
650515 - [On 071007 patient confirms Kaiser is working on paying UCSF for
650516 - medical services to treat Millie on referral, ref SDS 28 X58I, and
650517 - plans follow up call to get more information on UCSF billings,
650518 - ref SDS 28 IE3X; copy notifies UCSF of Kaiser's progress paying
650519 - UCSF billings. ref SDS 28 IE3R
650521 - ..
650522 - [On 071009 UCSF objects to being notified Kaiser is working on
650523 - paying UCSF for medical servides on referral by Kaiser,
650524 - ref SDS 30 X65I; Kaiser cites HIPPA authority, ref SDS 30 JJ8F,
650525 - frightens emotionally traumatized stage IV cancer patient to stop
650526 - helping UCSF collect payment from Kaiser, ref SDS 30 JJ40; UCSF
650527 - claims to have evidence Millie was informed of responsibility to
650528 - pay coinsurance charges for UCSF medical services ordered on
650529 - referral by Kaiser. ref SDS 30 N88P
650531 - ..
650532 - [On 071010 Millie received Paula's letter from MCRC dated 071006,
650533 - and submitted authorization for representation. ref SDS 32 TH8L
650535 - ..
650536 - [On 071025 Millie responded to Kaiser's letter, and submitted
650537 - authorization for representation. ref SDS 34 AM3K
650539 - ..
650540 - [On 071128 Kaiser Appeals Committee approved payment for Millie's
650541 - care on referral to UCSF. ref SDS 41 JZ5R
650543 - ..
650544 - [On 100528 0322 Millie asks for Jilin for Medicare CMS support
650545 - on a new case management problem. ref SDS 42 QQ6N
650546 -
650547 -
650548 -
650549 -
650551 - ..
6506 -
6507 -
6508 - Progress
6509 -
650901 - CMS Referral to Kaiser Member Relations Review Committee
650902 - Patient Emotional Unable Discuss Kaiser Failure Pay for Treatment
650903 -
650905 - ..
650906 - Paula called today, with Kaiser's Member Relations group in
650907 - Pleasanton. She works in the Member Case Resolution Center (MCRC),
650908 - and wanted to discuss the clinical trial referral issue set out in the
650909 - record of the meeting at UCSF on 070830. ref SDS 19 X16N
650911 - ..
650912 - Millie took the call. She has been emotional dealing with this issue
650913 - the past few months. During examination on 070921 the doctor asked
650914 - about coping with rising stress. ref SDS 23 QY9V Kaiser prescribed
650915 - pills for anxiety and referral for mental health consultation,
650916 - ref SDS 23 QY45, as noted in the medical chart. ref SDS 23 QY9V On
650917 - 070926 Karen with Kaiser Mental Health reported in a letter efforts to
650918 - investigate. ref SDS 24 QY5I Progress has been slow since that
650919 - letter. As a result, Millie was overwhelmed today by complexity of
650920 - multiple stakeholders, invoices, revisions, mind numbing details noted
650921 - in the letter to Kaiser on 070926, ref SDS 24 OS4G, jargon, and
650922 - conflicting numbers (see below, ref SDS 0 PRWW), and so was unable to
650923 - talk with Paula. Millie requested patienct assistance with the call.
650925 - ..
650926 - Paula was gracious apologizing for causing Millie to breakdown
650927 - receiving the call, and then was very effective cutting to the core of
650928 - regulatory, policy, and procedural problems in this case. Paula's
650929 - call today finally accomplished Doctor Rugo's recommendation in UCSF's
650930 - letter on 070906 to involve management and claims professional staff
650931 - at Kaiser. ref SDS 21 UK5M
650932 -
650933 -
650935 - ..
650936 - Letter 071002 to CMS and 50 Pages Patient History Millie Claim
650937 - 50 Pages Fax Documents Kaiser Received from CMS with Letter on 071002
650938 -
650939 - Paula advised that she recently received from Medicare CMS via fax a
650940 - copy of the letter reporting billing irregularities on Millie's care
650941 - at UCSF, and submitted to Medicare via email on 071002, ref SDS 26
650942 - KA5J, and for the purpose of confirming telephone discussion with Lee
650943 - at Medicare on 070927. ref SDS 25 VG8M Evidently, Lee, or possibly
650944 - Jullin Kwok, who handles the CMS contract with Kaiser for Medicare
650945 - services, printed the letter on 071002 along with 50 or so pages of
650946 - patient history cited in the letter, and then faxed all of this to
650947 - MCRC, which was then assigned to Paula for follow up. Paula said that
650948 - making sense of the 50 or so pages she received from CMS fax is a lot
650949 - of hard work. She called today for help.
650951 - ..
650952 - [...below, Paula requests submission of email with links to the
650953 - letter on 071002, which has further links into relevant patient
650954 - history. ref SDS 0 Q957
650956 - ..
650957 - [On 071009 Jullin called and advised that she received the
650958 - letter on 071002 to CMS, and also printed 50 pages of
650959 - references, ref SDS 29 EX5J; Jullin did not mention sending
650960 - this material to Paula at Kaiser, even though she manages
650961 - Medicare's contract with Kaiser, ref SDS 29 LT7J; Jullin said
650962 - she sent the letter on 071002 to CMS research department for
650963 - guidance on Medicare law to Millie's case. ref SDS 29 R66K
650965 - ..
650966 - [On 071010 for some reason Paula's letter dated today, 071006,
650967 - cites a "request for appeal" dated 071001, which conflicts with
650968 - her call today citing a fax Kaiser received from CMS for the
650969 - letter to CMS on 071002; Kaiser further cites appeal from a
650970 - determination, which Millie never made nor received.
650971 - ref SDS 32 TH8L
650973 - ..
650974 - [On 071029 Jim Mayhew reported he did not receive the
650975 - letter dated today, 071002, ref SDS 37 KA5J, due to email
650976 - problems at CMS, ref SDS 37 6N8R, resubmitted letter during
650977 - call; Jim reported he received it; after discussion, Jim
650978 - agreed to assign someone to make a review independent from
650979 - CMS in San Francisco. ref SDS 37 0Z5J
650981 - ..
650982 - [On 071029 Jullin advised CMS preparing written response to
650983 - letter to CMS dated 071002 on statutory autority for payment
650984 - responsibility when patient self-refers for treatment in a
650985 - clinical trial, and distinguished from when the doctor
650986 - prescribes treatment in a clinical trial. ref SDS 37 WP7O
650988 - ..
650989 - [On 071030 Paula confirmed that the date of 071001 in Kaiser's
650990 - letter today was mistake, since Kauser framed an appeal for
650991 - Millie based on the letter to CMS dated 071002 which CMS sent
650992 - to Kaiser. ref SDS 38 V26V
650994 - ..
650995 - [On 100528 0322 Millie asks for Jilin for Medicare CMS support
650996 - on a new case management problem. ref SDS 42 QQ6N
650998 - ..
650999 - Paula seemed further to indicate that her work entails communicating
651000 - with Kaiser customers, like Millie, to assemble issues and background
651001 - for presentation to a Kaiser internal review panel, committee, etc.
651002 - She came into the office today on Saturday in order to expedite
651003 - resolution of the UCSF payment issue, and called for assistance on why
651004 - Kaiser referred Millie to UCSF for treatment in a clinical trial.
651005 -
651006 -
651007 -
6511 -
SUBJECTS
MCRC Appeal Committee Senior Case Manager Recommend Kaiser Pay for P
AQ03 -
AQ0401 - ..
AQ0402 - MCRC Recommend Kaiser Pay for Prescribed Treatment UCSF Clinical Trial
AQ0403 -
AQ0404 - Paula explained plans to request that Kaiser submit the doctor's
AQ0405 - authorization to UCSF for Millie to continue getting treatment on
AQ0406 - referral with cetuximab and carboplatin originally prescribed on
AQ0407 - 070105, ref SDS 12 PK7L, and confirmed by the doctor's letter to
AQ0408 - Millie on 070119. ref SDS 13 4R4M Since treatment drugs are paid by a
AQ0409 - clinical trial, Kaiser saves considerable expense, paying only for
AQ0410 - standard of care, as agreed by Kaiser and UCSF on 061230. ref SDS 11
AQ0411 - 3X6K Kaiser has no grounds for "double dipping" on cost savings by
AQ0412 - transferring payment for cost of prescribed care to the patient, as
AQ0413 - noted in the record on 070830. ref SDS 19 NQ3F
AQ0414 -
AQ0415 - [On 071009 USACE representative claims to have received notice
AQ0416 - from unnamed people at Kaiser that the patient was told the
AQ0417 - patient would be responsible for coinsurance in Kaiser's
AQ0418 - transaction arranging for treatment on referral at UCSF.
AQ0419 - ref SDS 30 N88P
AQ0421 - ..
AQ0422 - [On 071030 Paula plans to propose Kaiser pay outstanding
AQ0423 - charges for referral on clinical trial, and submit the doctor's
AQ0424 - authorization so that UCSF can bill Kaiser going forward.
AQ0426 - ..
AQ0427 - Paula cautioned not to set high expectations for solutions.
AQ0428 -
AQ0429 - [On 071030 Paula planning presentation to Appeals Committee for
AQ0430 - Kaiser to pay UCSF for Millie's treatment in clinical trial,
AQ0431 - and note Paula's warning not to set high expectations.
AQ0432 - ref SDS 38 JA6S
AQ0433 -
AQ0434 -
AQ0435 -
AQ0436 -
AQ0437 -
AQ05 -
SUBJECTS
Patient Designate Representative Handle MCRC Review Process Appearan
BB03 -
BB0401 - ..
BB0402 - Patient Can Designate Representative for Handling MCRC Review Process
BB0403 -
BB0404 - Paula advised that Millie can designate a representative to meet with
BB0405 - Kaiser's review Appeal Committee. Paula is preparing a letter to
BB0406 - explain the appeal process. The letter will transmit forms for Millie
BB0407 - to designate an authorized representative to attend the Appeal meeting
BB0408 - for Millie.
BB0409 -
BB0410 - [On 071010 Millie received Paula's letter from MCRC dated 071006,
BB0411 - and submitted authorization for representation. ref SDS 32 TH8L
BB0413 - ..
BB0414 - [On 071025 Millie responded to Kaiser's letter, and
BB0415 - submitted authorization for representation. ref SDS 34 AM3K
BB0417 - ..
BB0418 - [On 071026 Millie sent email notifying Paula at Kaiser that
BB0419 - she had mailed the letter on 071025. ref SDS 36 WC4N
BB0421 - ..
BB0422 - Often internal hearings are objective and strive for equity that
BB0423 - balances competing interests. Appearance aids good faith internal
BB0424 - hearings. Sometimes internal panels simply endorse pro forma official
BB0425 - views, because understanding complex cases requires a lot of hard
BB0426 - work. Difficulty developing lessons learned presents a continuing
BB0427 - knowledge management dilemma, reported on 000307. ref SDS 2 767G
BB0429 - ..
BB0430 - Paula explained experience of a family member being treated for cancer
BB0431 - in the Kaiser Walnut Creek facility, and has high regard for Millie's
BB0432 - doctor by reputation (another doctor treated her family member). She
BB0433 - is familiar with many of the staff in the Oncology department, and
BB0434 - joins Millie commending Kaiser's high standards of care, noted
BB0435 - previously on 020221. ref SDS 3 Y47O Paula understands strong
BB0436 - emotional swings that cancer patients experience, illustrated today,
BB0437 - ref SDS 0 ZE9H, noted by the doctor on 070921, and further evident in
BB0438 - the record meeting at Kaiser on 070105. ref SDS 12 Y642
BB0443 -
BB0444 -
BB0445 -
BB05 -
SUBJECTS
Kaiser MCRC Appeals Committee Review Compex Patient History 16 Legal
CO03 -
CO0401 - ..
CO0402 - Making Sense of Complexity Precision Access for Knowledge Management
CO0403 - Knowledge Management Precision Access Enables Concurrent Discovery
CO0404 -
CO0405 - Follow up ref SDS 27 7G5G.
CO0406 -
CO0407 - Paula seemed to indicate Medicare CMS notified Kaiser that Millie's
CO0408 - case presents important policy issues, which require careful review to
CO0409 - make sense of complex patient history, shown by 16 issues on 070927.
CO0410 - ref SDS 25 WU6M Paula's report today aligns with the call on 071003
CO0411 - from Jullin at CMS, who cited complexity of the case. ref SDS 27 BZ40
CO0413 - ..
CO0414 - [On 100528 0322 Millie asks for Jilin for Medicare CMS support
CO0415 - on a new case management problem. ref SDS 42 QQ6N
CO0417 - ..
CO0418 - Today, Paula requested assistance making sense of complex patient
CO0419 - history working with 50 or so pages of printed documents which Kaiser
CO0420 - received from CMS, per above. ref SDS 0 Z87L
CO0422 - ..
CO0423 - [On 071009 Jullin called and said she submitted the letter to
CO0424 - CMS on 071002, along with 50 pages she printed from citations
CO0425 - in the letter, for "research" on whether Medicare Senior
CO0426 - Advantage managed care supports physician and self referrals;
CO0427 - her understanding is that Medicare law prohibits physician
CO0428 - referrals, ref SDS 29 EX5J; Jullin did not say that she sent
CO0429 - the letter on 071002 to Paula at Kaiser. ref SDS 29 LT7J
CO0431 - ..
CO0432 - Printed documents are difficult to handle. Paper is bulky and inert,
CO0433 - lacking the power of knowledge using precision access available with
CO0434 - electronic data, explained in NWO. ref OF 13 PX6J This was discussed
CO0435 - with Jullin Kwok at CMS on 071003, and she decided to read the letter
CO0436 - online, rather than a printed version. ref SDS 27 BZ4N Problems
CO0437 - making sense of complex work history fumbling through mountains of
CO0438 - paper was illustrated by Doctor Benz at UCSF on 041018, ref SDS 6
CO0439 - QU6F, and again on 060821. ref SDS 8 0I4N
CO0441 - ..
CO0442 - Paula requested a copy of the original letter submitted via email in
CO0443 - order to have immediate electronic access to verify background and
CO0444 - understand context that aids discussion today, and going forward.
CO0445 -
CO0446 -
CO0447 -
CO0448 -
CO0449 -
CO0450 -
CO0451 -
CO05 -
SUBJECTS
CMS Letter 071002 Request Clarification Mdicare Law Distinguish Doc
DS03 -
DS04 - 1549
DS0501 - ..
DS0502 - Email Transmit Letter CMS 071002 for Precision Access Patient History
DS0503 -
DS0504 - During the call, and per Paula's request, ref SDS 0 M15M, submitted a
DS0505 - letter, ref DIT 1 0001, to Paula at Kaiser MCRC, and which transmitted
DS0506 - the original letter, ref DIP 5 0001, sent to Lee at CMS on 071002,
DS0507 - ref SDS 26 KA5J, with attachments. ref SDS 26 FE6H This gives Paula
DS0508 - and the MCRC team at Kaiser immediate, precision access to background
DS0509 - without fumbling through stacks of paper, per above, ref SDS 0 9P5J,
DS0510 - by clicking links, using judicious review explained in NWO.
DS0511 - ref OF 15 1M7G
DS0512 -
DS0513 - [On 071030 Paula confirmed that the date of 071001 in
DS0514 - Kaiser's letter today was mistake, since Kaiser framed an
DS0515 - appeal for Millie based on the letter to CMS dated 071002
DS0516 - which CMS sent to Kaiser. ref SDS 38 V26V
DS0517 -
DS0518 -
DS0519 -
DS0520 -
DS06 -
SUBJECTS
Kaiser MCRC Appeals Committee Review Compex Patient History 16 Legal
F503 -
F50401 - ..
F50402 - Links Precision Access Instantaneous Connections Make Sense Complexity
F50403 - Making Sense Complex Patient History 2 Minutes Learn Knowledge Space
F50404 - 2 Minutes Learn Navigate Knowledge Space Understand Complex Patient History
F50405 -
F50406 - After receiving via email during the call today the transmittal, per
F50407 - above, ref SDS 0 Q957, Paula opened the letter dated 071002 to CMS
F50408 - online. ref DIP 5 0001 She clicked the link in paragraph 2,
F50409 - ref DIP 5 NN6K, that opens patient history on 070105 answering Paula's
F50410 - question about why Kaiser prescribed treatment for Millie at UCSF,
F50411 - ref SDS 12 PK68, reported further below. ref SDS 0 Q969
F50413 - ..
F50414 - Paula invested a few minutes for instruction learning to nagivate in
F50415 - SDS Knowledge Space, explained in POIMS, ref OF 6 XQ9F, similar to
F50416 - discussion with DCMA on 020905, ref SDS 4 DAPW, and used to organize
F50417 - the record of patient history in Millie's case (see case studies on
F50418 - 061018, ref SDS 9 0001)...
F50419 -
F50420 - 1. Date and description of SDS records are always shown at the
F50421 - top of the browser to position the record chronologically;
F50422 - this conveys sequence and causation, based on work context.
F50424 - ..
F50425 - 2. Links go to precise locations to get background for
F50426 - context, and to verify accuracy of representations.
F50427 - ref OF 13 PX6J; for example, during the call today Paula
F50428 - asked for the original correspondence between Kaiser and
F50429 - UCSF on Millie's referral for treatment. ref SDS 0 Q969
F50431 - ..
F50432 - 3. Line numbers aid navigation with unique addressing that
F50433 - facilitates collaboration, as occurred during the call
F50434 - today, and explained on 890523. ref SDS 1 T1VQ
F50435 -
F50436 -
F50437 -
F505 -
SUBJECTS
Patient Goals Payment Dispute Kaiser UCSF Continue Effective Treatme
FQ03 -
FQ0401 - ..
FQ0402 - Millie's Objective Continue Care at UCSF Resolve Payment Problems
FQ0403 -
FQ0404 - Follow up ref SDS 19 T94H.
FQ0405 -
FQ0406 - Initially discussed Millie's objective to continue treatment at UCSF
FQ0407 - which has proven very effective, and to benefit from future treatments
FQ0408 - available at UCSF, reported on 070130, ref SDS 14 TG5G, and planned by
FQ0409 - the primary care physician at Kaiser on 061208. ref SDS 10 P256 This
FQ0410 - requires addressing payment issues listed in the record meeting with
FQ0411 - UCSF on 070830, ref SDS 19 T94O, including new issues today, shown
FQ0412 - below. ref SDS 0 PRWW
FQ0413 -
FQ0414 - [On 071030 Paula asked how long Millie's treatment will
FQ0415 - last at UCSF, and goals for resolution of dispute between
FQ0416 - Kaiser and UCSF. ref SDS 38 UB4O
FQ0418 - ..
FQ0419 - Paula was pleased to hear treatment at UCSF has been effective for
FQ0420 - Millie, reported in a letter to UCSF and Kaiser on 070831. ref SDS 20
FQ0421 - G15I We need to get financials configured to everyone's satisfaction,
FQ0422 - so that excellent medical teamwork between Kaiser and UCSF, noted by
FQ0423 - the primary care physician at Kaiser on 070921, ref SDS 23 CU5K, can
FQ0424 - continue to benefit Millie, and lay groundwork for others.
FQ0426 - ..
FQ0427 - [On 071007 patient confirms Kaiser is working on paying
FQ0428 - UCSF for medical services to treat Millie on referral,
FQ0429 - ref SDS 28 X58I, and plans follow up call to get more
FQ0430 - information on UCSF billings, ref SDS 28 IE3X; copy
FQ0431 - notifies UCSF of Kaiser's progress paying UCSF billings.
FQ0432 - ref SDS 28 IE3R
FQ0434 - ..
FQ0435 - [On 071009 UCSF objects to being notified Kaiser is working
FQ0436 - on paying UCSF for medical servides on referral by Kaiser,
FQ0437 - ref SDS 30 X65I; Kaiser cites HIPPA authority, ref SDS 30
FQ0438 - JJ8F, frightens emotionally traumatized stage IV cancer
FQ0439 - patient to stop helping UCSF collect payment from Kaiser,
FQ0440 - ref SDS 30 JJ40; UCSF claims to have evidence Millie was
FQ0441 - informed of responsibility to pay coinsurance charges for
FQ0442 - UCSF medical services ordered on referral by Kaiser.
FQ0443 - ref SDS 30 N88P
FQ0444 -
FQ0445 -
FQ0446 -
FQ0447 -
FQ05 -
SUBJECTS
Kaiser Referral UCSF Treatment Clinical Trial Patient Did Not Self-r
GD03 -
GD0401 - ..
GD0402 - Kaiser Presented Millie Treatment at UCSF Patient Did Not Self-refer
GD0403 -
GD0404 - Paula asked when the original referral was made prescribing treatment
GD0405 - with cetuximab and carboplatin at UCSF? She cannot find in Kaiser's
GD0406 - records on the computer or in the files when this was done and the
GD0407 - reason for referral establishing Kaiser's duty to pay for the work.
GD0408 -
GD0409 - [On 071009 USACE representative claims to have received notice
GD0410 - from unnamed people at Kaiser that the patient was told the
GD0411 - patient would be responsible for coinsurance in Kaiser's
GD0412 - transaction arranging for treatment on referral at UCSF.
GD0413 - ref SDS 30 N88P
GD0415 - ..
GD0416 - We clicked on the link in the letter dated 071002 to CMS, per above,
GD0417 - ref SDS 0 Q957, to open the record on 070105. ref SDS 12 PK68 Paula
GD0418 - noticed the doctor changed the prescription from Navelbine to
GD0419 - cetuximab and carboplatin at that time on 070105, because these drugs
GD0420 - are newer treatments that only attack cancer, and so are more
GD0421 - effective, and cause fewer debilitating side effects. Treatment with
GD0422 - cetuximab and carboplatin change Millie's rare condition of "triple
GD0423 - negative" from a liability to an asset by expanding the pool of drugs
GD0424 - in her case, ref SDS 12 G44N, and so preserve the few remaining
GD0425 - established treatments for use later to preserve her life, as planned
GD0426 - by the doctor during the meeting at Kaiser on 040318. ref SDS 5 DG4J
GD0428 - ..
GD0429 - Paula said that access to information she needs simply by clicking a
GD0430 - link in SDS records on the Internet is amazing.
GD0432 - ..
GD0433 - Paula asked about arrangements between UCSF and Kaiser to pay for
GD0434 - Millie's treatment? She clicked on the link for the record a week
GD0435 - earlier on 061230 that shows arrangements between Kaiser and UCSF.
GD0436 - ref SDS 11 3X6K
GD0437 -
GD0438 - [On 071009 USACE representative claims to have received notice
GD0439 - from unnamed people at Kaiser that the patient was told the
GD0440 - patient would be responsible for coinsurance in Kaiser's
GD0441 - transaction arranging for treatment on referral at UCSF.
GD0442 - ref SDS 30 N88P
GD0444 - ..
GD0445 - Paula requested the doctor's original letter transmitting Kaiser's
GD0446 - correspondence with Doctor Rugo at UCSF on 061230. Kaiser has this
GD0447 - document on file generated by Millie's primary care physician using
GD0448 - Kaiser's email system for patient communication. Normally, original
GD0449 - physician correspondence is not displayed on the Internet. Paula said
GD0450 - it is easier to get the letter from SDS than from Kaiser's computer
GD0451 - system. She hates to bother the doctor and his staff, who are busy
GD0452 - treating patients, with administrative activities to find documents.
GD0453 - To facilitate Paula's review today, a version of Kaiser's letter dated
GD0454 - 061230, ref DRP 6 0001, was made active on the Internet and without
GD0455 - identification of the patient and the primary care physician.
GD0457 - ..
GD0458 - Paula downloaded the Kaiser's letter dated, and then the document was
GD0459 - removed from the Internet.
GD0460 -
GD0461 -
GD0462 -
GD0463 -
GD0464 -
GD05 -
SUBJECTS
Coinsurance 20% Self-referral EOC Section 7 Clinical Trials Not Appl
H403 -
H40401 - ..
H40402 - Continuing Condition Requires Continuing Care by Kaiser
H40403 - EOC Applied Millie's Patient History Clinical Trials No Coinsurance
H40404 -
H40405 - Paula asked for terms and conditions of clinical trials in Millie's
H40406 - Evidence of Coverage (EOC) for 2007. This was recently reviewed on
H40407 - 070927. ref SDS 25 166L
H40409 - ..
H40410 - Paula asked why Millie was not aware on 070105 when the doctor
H40411 - prescribed treatment in a clinical trial, that she would be liable for
H40412 - paying coinsurance at 20% of costs paid by Medicare to the service
H40413 - provider (here "UCSF"), as stated on page 68 describing terms and
H40414 - conditions of clinical trials for Senior Advantage members?
H40415 - ref SDS 25 1F67
H40416 -
H40417 - [On 071009 USACE representative claims to have received notice
H40418 - from unnamed people at Kaiser that the patient was told the
H40419 - patient would be responsible for coinsurance in Kaiser's
H40420 - transaction arranging for treatment on referral at UCSF.
H40421 - ref SDS 30 N88P
H40423 - ..
H40424 - This issue is reviewed on 070927 concerning case management specified
H40425 - in EOC section 2 requiring patient reliance on the doctor for a single
H40426 - point of contact, ref SDS 25 8G5N, which is issue #1 citing Kaiser's
H40427 - pattern and practice treating the patient for the past 6 years.
H40428 - ref SDS 25 WL5G It is reviewed again in issue #10. ref SDS 25 WV6I
H40430 - ..
H40431 - Paula noticed in the record on 070927 review of patient history citing
H40432 - case study of this issue on 070830. ref SDS 19 LQ5I Kaiser had not
H40433 - previously charged 20% coinsurance for similar work under the same
H40434 - insurance coverage, as further noted on 070830. ref SDS 19 T14M
H40435 - Millie had never read Kaiser's EOC documents because at all times
H40436 - Kaiser's conduct determined application of written expressions in the
H40437 - EOC. Kaiser acted correctly on 061230 to retain responsibility for
H40438 - treatment of a continuing condition by referring Millie for treatment
H40439 - at UCSF, ref SDS 11 3X6K, as noted in the record on 070830. ref SDS 19
H40440 - T94O Accordingly, Millie did not present to UCSF for self-referral to
H40441 - participate in a clinical trial, but rather was presented by Kaiser
H40442 - for treatment prescribed by the doctor of a continuing condition, and
H40443 - the doctor notified UCSF that Kaiser would pay any costs, as occurred
H40444 - on prior clinical trial treatments. (see again the study on 070830,
H40445 - ref SDS 19 LQ5I)
H40447 - ..
H40448 - Common practice for Kaiser to refer patients for needed treatment
H40449 - without incurring additional expense was reported by Kaiser in a
H40450 - letter to Millie on 060809. ref SDS 7 NT9X
H40452 - ..
H40453 - Paula will check Kaiser's coverage for changes between prior referrals
H40454 - in 2004, and the EOC for 2007, reviewed on 070927. ref SDS 25 166L
H40455 - This research could resolve conflict between EOC section 7 saying
H40456 - patients have to pay coinsurance, and Kaiser's documentation saying
H40457 - patiens may have to pay coinsurance on clinical trials. ref SDS 25
H40458 - 1F67
H40460 - ..
H40461 - Paula plans to contact the primary care physician for the medical
H40462 - intent in this case, as stated in correspondence between Kaiser and
H40463 - UCSF on 061230. ref SDS 11 3X6K Paula also wants to track down what
H40464 - happened to the authorization reported submitted on 070119.
H40465 - ref SDS 13 4R4M
H40466 -
H40467 - [On 071030 Paula confirmed that the doctor intended to make
H40468 - a referral for Millie's treatment in a clinical trial at
H40469 - UCSF; she could not find what happened to the referral that
H40470 - resulted in Kaiser denying payments for lack of
H40471 - authorization. ref SDS 38 FN3H
H40473 - ..
H40474 - Paula will review the record on 070830 that presents UCSF billing
H40475 - practices with relevant case studies on patient history. ref SDS 19
H40476 - 0000 She will call back tomorrow for more background on patient
H40477 - history in this case.
H40478 -
H40479 - [On 071007 patient confirms Kaiser is working on paying
H40480 - UCSF for medical services to treat Millie on referral,
H40481 - ref SDS 28 X58I, and plans follow up call to get more
H40482 - information on UCSF billings, ref SDS 28 IE3X; copy
H40483 - notifies UCSF of Kaiser's progress paying UCSF billings.
H40484 - ref SDS 28 IE3R
H40486 - ..
H40487 - [On 071009 UCSF objects to being notified Kaiser is working
H40488 - on paying UCSF for medical servides on referral by Kaiser,
H40489 - ref SDS 30 X65I; Kaiser cites HIPPA authority, ref SDS 30
H40490 - JJ8F, frightens emotionally traumatized stage IV cancer
H40491 - patient to stop helping UCSF collect payment from Kaiser,
H40492 - ref SDS 30 JJ40; UCSF claims to have evidence Millie was
H40493 - informed of responsibility to pay coinsurance charges for
H40494 - UCSF medical services ordered on referral by Kaiser.
H40495 - ref SDS 30 N88P
H40497 - ..
H40498 - [On 071030 Paula seems familiar with patient history on
H40499 - billing issues between Kaiser and UCSF. ref SDS 38 FM6J
H40500 -
H40501 -
H40502 -
H40503 -
H40504 -
H406 -
SUBJECTS
UCSF Justification Charges Financial Engineering Resolve Billing Irr
I603 -
I60401 - ..
I60402 - Financial Engineering Billing Irregularities Needs Justification Charges
I60403 - Irregularities Billings Requires Careful Review Justify Payment
I60404 - Justification UCSF Charges Required Payment Avoid Billing Irregularities
I60405 - Billings Clinical Trials Need Audit Trail Between Work and Requirements
I60406 -
I60407 - Regardless of who pays for the work, UCSF billing irregularities need
I60408 - close review by medical professionals for improper financial
I60409 - engineering, as follows...
I60410 -
I60411 - 1. On 070823 UCSF was asked for a total of all charges in order
I60412 - for the patient to make sense of a great many invoices and
I60413 - conflicting statements received all at once for activity
I60414 - beginning in January. ref SDS 18 X05R At that time a meeting
I60415 - was scheduled with UCSF to review their total claim against
I60416 - Millie. ref SDS 18 Y54M
I60417 -
I60418 - [On 071010 UCSF refuses to explain charges in complex
I60419 - billings; refers patient Medicare. ref SDS 31 OH7R
I60421 - ..
I60422 - [On 071026 UCSF billing irregularies designed to extract
I60423 - payment not justified by patient history. ref SDS 35
I60424 - UW5J
I60426 - ..
I60427 - [On 071026 UCSF demands payment in full within one week,
I60428 - ref SDS 35 SU5V, of billed amounts without resolving
I60429 - billing irregularities, ref SDS 35 X18J, and insisting
I60430 - Millie contact Medicare to explain UCSF billings.
I60431 - ref SDS 35 SU6R
I60433 - ..
I60434 - [On 071031 UCSF threatens termination of treatment
I60435 - unless patient pays $202. ref SDS 39 KM4J
I60437 - ..
I60438 - 2. On 070830 UCSF submitted during a meeting at their offices a
I60439 - total amount claimed against Millie summarized in a
I60440 - spreadsheet. ref SDS 19 WP5I The amount of recovery billed to
I60441 - Millie at that time was $4,254.12 as of 070802, which was 56%
I60442 - of amounts paid by Medicare. ref SDS 19 GR8F
I60444 - ..
I60445 - 3. During the meeting on 070830 UCSF identified charges for doctor
I60446 - visits as amounts shown of $110.00. ref SDS 19 VT5W There was
I60447 - agreement at that time for Millie to pay copayments at a rate
I60448 - that varied from $22 - $27 (for unknown reasons), however, this
I60449 - was in the ballpark of copayments for doctor examinations at
I60450 - Kaiser. On 070906 Millie paid these copayments by check for
I60451 - work from inception on 070130 through 070621, which were listed
I60452 - in the UCSF spreadsheet. ref SDS 21 EB3P
I60454 - ..
I60455 - 4. On 070917 Millie received a letter from UCSF dated 070812
I60456 - revising the total claimed on 070830 from $4,254.12 down to
I60457 - $1,506.60. Since she had already paid $312 for the doctor
I60458 - visits, UCSF's total claim for coinsurance was for $1,194.52.
I60459 - ref SDS 22 595P
I60461 - ..
I60462 - While this is a substantial move toward a solution, questions
I60463 - remain....
I60464 -
I60465 - a. What rates are being charged relative to the statute?
I60466 -
I60467 - Today, Paula seemed confident this is limited to 20% based
I60468 - on review of Kaiser's clinical trial EOC, listed on 070927.
I60469 - ref SDS 25 1F67 The EOC actually says "generally 20%,"
I60470 - which leaves room for financial engineering. Moreover,
I60471 - UCSF is not bound by Kaiser's EOC, although Kaiser and UCSF
I60472 - can negotiate to set an actual rate for this transaction.
I60473 - Review on 070917 indicates Title 42 part 419.40 sets 20% as
I60474 - a minimum rate, and does not seem to set an upper limit;
I60475 - rather, it appears policy intends for market competition to
I60476 - constrain coninsurance rates. ref SDS 22 4Q3I Obviously
I60477 - Kaiser is a powerful market force for setting reasonable
I60478 - limits, which is why Kaiser should be involved, rather than
I60479 - an enfeebled, emotional cancer patient, cited in the
I60480 - medical chart, per above. ref SDS 0 ZE9H
I60482 - ..
I60483 - b. What charges are subject to coinsurance rates?
I60484 - Specifically, UCSF invoices appear to charge for
I60485 - chemotherapy, shown on 070830. ref SDS 19 F94O On 061230
I60486 - UCSF indicated to Kaiser that this work was "funded," but
I60487 - "standard of care" is not covered. ref SDS 11 IV6K This
I60488 - suggests that coinsurance in this case should only be
I60489 - charged for "standard of care" costs. What does that
I60490 - encompass as a base for applying coinsurance rates?
I60491 -
I60492 - [On 071007 patient confirms Kaiser is working on paying
I60493 - UCSF for medical services to treat Millie on referral,
I60494 - ref SDS 28 X58I, and plans follow up call to get more
I60495 - information on UCSF billings, ref SDS 28 IE3X; copy
I60496 - notifies UCSF of Kaiser's progress paying UCSF billings.
I60497 - ref SDS 28 IE3R
I60499 - ..
I60500 - [On 071009 UCSF objects to being notified Kaiser is
I60501 - working on paying UCSF for medical servides on referral
I60502 - by Kaiser, ref SDS 30 X65I; Kaiser cites HIPPA
I60503 - authority, ref SDS 30 JJ8F, frightens emotionally
I60504 - traumatized stage IV cancer patient to stop helping UCSF
I60505 - collect payment from Kaiser, ref SDS 30 JJ40; UCSF
I60506 - claims to have evidence Millie was informed of
I60507 - responsibility to pay coinsurance charges for UCSF
I60508 - medical services ordered on referral by Kaiser.
I60509 - ref SDS 30 N88P
I60511 - ..
I60512 - [On 071010 UCSF refuses to explain charges in complex
I60513 - billings; refers patient to 3rd part. ref SDS 31 OY7N
I60514 -
I60515 -
I60516 -
I60517 -
I606 -
SUBJECTS
UCSF Duplicate Billings Doctor Visits Pink Invoices Justification Ch
JE03 -
JE0401 - ..
JE0402 - $20K Additional Annual Charges for Millie's Treatment at UCSF
JE0403 - New Billings Doctor Visits Appear Duplication Prior Payments
JE0404 -
JE0405 -
JE0406 - 5. Today, Millie received in the mail from UCSF a 4 page invoice
JE0407 - #45772381 dated 071003 (October 3, 2007) and in the amount of
JE0408 - $2,2264.00. This is the total of a series of charges dating
JE0409 - from the first date Millie met with the medical team at UCSF on
JE0410 - 070130. The charge for services on 070130 is shown as $371.00.
JE0411 - Charges continue through 070419, and are described as for level
JE0412 - 4 and level 5 medical services. UCSF, thus seeks $2.2K for 3
JE0413 - months medical services, which calculates to about another $10K
JE0414 - annually.
JE0415 -
JE0416 - [On 071007 patient confirms Kaiser is working on paying
JE0417 - UCSF for medical services to treat Millie on referral,
JE0418 - ref SDS 28 X58I, and plans follow up call to get more
JE0419 - information on UCSF billings, ref SDS 28 IE3X; copy
JE0420 - notifies UCSF of Kaiser's progress paying UCSF billings.
JE0421 - ref SDS 28 IE3R
JE0423 - ..
JE0424 - [On 071009 UCSF objects to being notified Kaiser is working
JE0425 - on paying UCSF for medical servides on referral by Kaiser,
JE0426 - ref SDS 30 X65I; Kaiser cites HIPPA authority, ref SDS 30
JE0427 - JJ8F, frightens emotionally traumatized stage IV cancer
JE0428 - patient to stop helping UCSF collect payment from Kaiser,
JE0429 - ref SDS 30 JJ40; UCSF claims to have evidence Millie was
JE0430 - informed of responsibility to pay coinsurance charges for
JE0431 - UCSF medical services ordered on referral by Kaiser.
JE0432 - ref SDS 30 N88P
JE0434 - ..
JE0435 - [On 071010 Millie asks UCSF for explanation of new charges
JE0436 - with pink invoices. ref SDS 31 HZ6S
JE0438 - ..
JE0439 - [On 071010 UCSF explains new pink invoices are charges
JE0440 - from another UCSF business unit, ref SDS 31 OH89, and
JE0441 - further explains UCSF white invoices cover level 4 and
JE0442 - level 5 services, which indicates that the pink invoices
JE0443 - duplcate charges already paid. ref SDS 31 OH83
JE0445 - ..
JE0446 - [On 071128 Kaiser Appeals Committee approved payment for
JE0447 - Millie's care on referral to UCSF. ref SDS 41 JZ5R
JE0449 - ..
JE0450 - Does this mean there is another $2K out there to be billed for
JE0451 - the period from May to the present?
JE0453 - ..
JE0454 - This $2.2K appears to duplicate charges designated as UCSF's
JE0455 - total claim on 070830, and more than doubles the amount UCSF
JE0456 - claimed was owed as its total claim in their letter on 070912,
JE0457 - reviewed on 070917. ref SDS 22 J14R
JE0459 - ..
JE0460 - UCSF's initial billings presented at the accounting department
JE0461 - on 070830 calculated at $10K per year. ref SDS 19 X16N Adding
JE0462 - annualized charges received today of another $10K indicate UCSF
JE0463 - seeks approximately $20K per year above Millie's insurance
JE0464 - premiums paid to Kaiser and to Medicare.
JE0466 - ..
JE0467 - What other UCSF business units will be submitting billings
JE0468 - which have not yet been presented to the patient?
JE0469 -
JE0470 - [On 071010 Millie requests clarification of billings from
JE0471 - multiple business units at UCSF. ref SDS 31 HZ6S
JE0472 -
JE0473 - [On 071010 UCSF advises pink invoices for MGBS; review
JE0474 - is underway to determine total being claimed. ref SDS 31
JE0475 - OH89
JE0477 - ..
JE0478 - [On 071011 Millie asks UCSF about other business units
JE0479 - billing for clinical trial services which have not yet been
JE0480 - explained to the customer? ref SDS 33 K64T
JE0482 - ..
JE0483 - [On 071011 Millie asks if there are green, yellow, other
JE0484 - colored invoices still to be billed? ref SDS 33 K65S
JE0486 - ..
JE0487 - [On 071011 Millie requests clarify on what is owed to UCSF
JE0488 - for clinical trial services. ref SDS 33 K65S
JE0490 - ..
JE0491 - These questions should be reviewed in a referral coordination
JE0492 - plan meeting, ref SDS 16 KL5G, noted in the record on 070222,
JE0493 - and still pending. ref SDS 16 VK5N
JE0495 - ..
JE0496 - 6. Undoubtedly there is a good explanation, and these are very
JE0497 - fascinating issues for medical financial professionals. They
JE0498 - conflict with UCSF's notice on every floor of the hospital that
JE0499 - lists the first patient bill of rights is the right to clear
JE0500 - and direct information; and futher conflicts with Kaiser's
JE0501 - treatment objectives for a 72 year old stage IV cancer patient
JE0502 - fighting for survival on relapse #4 of a highly aggressive
JE0503 - cancer, as noted by Millie's doctor in the medical chart during
JE0504 - the meeting at Kaiser on 070921. ref SDS 23 Y53O
JE0505 -
JE0506 -
JE0507 -
JE0508 -
JE0510 - ..
JE06 -
JE07 -
JE08 - 1711
JE09 -
JE0901 - Paula had to end the call. She plans to call back tomorrow for
JE0902 - further assistance assembling a presentation for the review panel.
JE0904 - ..
JE0905 - Submitted this record for review to continue work tomorrow.
JE0906 -
JE0907 -
JE0908 -
JE0909 -
JE0910 -
JE0911 -
JE10 -