THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: October 6, 2007 03:39 PM Saturday;
Kaiser called about Millie's referral to UCSF for treatment of IBC.
2...CMS Referral to Kaiser Member Relations Review Committee
3...Patient Emotional Unable Discuss Kaiser Failure Pay for Treatment
4...Letter 071002 to CMS and 50 Pages Patient History Millie Claim
5...50 Pages Fax Documents Kaiser Received from CMS with Letter on 071002
6...MCRC Recommend Kaiser Pay for Prescribed Treatment UCSF Clinical Trial
7...Patient Can Designate Representative for Handling MCRC Review Process
8...Making Sense of Complexity Precision Access for Knowledge Management
9...Knowledge Management Precision Access Enables Concurrent Discovery
10...Email Transmit Letter CMS 071002 for Precision Access Patient History
11...Links Precision Access Instantaneous Connections Make Sense Complexity
12...Making Sense Complex Patient History 2 Minutes Learn Knowledge Space
13...2 Minutes Learn Navigate Knowledge Space Understand Complex Patient History
14...Millie's Objective Continue Care at UCSF Resolve Payment Problems
15...Kaiser Presented Millie Treatment at UCSF Patient Did Not Self-refer
16...Continuing Condition Requires Continuing Care by Kaiser
17...EOC Applied Millie's Patient History Clinical Trials No Coinsurance
18...Financial Engineering Billing Irregularities Needs Justification Charges
19...Irregularities Billings Requires Careful Review Justify Payment
20...Justification UCSF Charges Required Payment Avoid Billing Irregularities
21...Billings Clinical Trials Need Audit Trail Between Work and Requirements
22...$20K Additional Annual Charges for Millie's Treatment at UCSF
23...New Billings Doctor Visits Appear Duplication Prior Payments
Click here to comment!
1...Paula will check Kaiser's coverage for changes between prior referrals
CMS Referral Clinical Trial Referral Coinsurance Payment Dispute UCS
6503 - ..
6504 - Summary/Objective
650501 - Follow up ref SDS 26 0000. ref SDS 25 0000.
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
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
650551 - ..
6508 - Progress
650901 - CMS Referral to Kaiser Member Relations Review Committee
650902 - Patient Emotional Unable Discuss Kaiser Failure Pay for Treatment
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
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
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.
MCRC Appeal Committee Senior Case Manager Recommend Kaiser Pay for P
AQ0401 - ..
AQ0402 - MCRC Recommend Kaiser Pay for Prescribed Treatment UCSF Clinical Trial
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
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.
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
Patient Designate Representative Handle MCRC Review Process Appearan
BB0401 - ..
BB0402 - Patient Can Designate Representative for Handling MCRC Review Process
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.
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
Kaiser MCRC Appeals Committee Review Compex Patient History 16 Legal
CO0401 - ..
CO0402 - Making Sense of Complexity Precision Access for Knowledge Management
CO0403 - Knowledge Management Precision Access Enables Concurrent Discovery
CO0405 - Follow up ref SDS 27 7G5G.
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.
CMS Letter 071002 Request Clarification Mdicare Law Distinguish Doc
DS04 - 1549
DS0501 - ..
DS0502 - Email Transmit Letter CMS 071002 for Precision Access Patient History
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
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
Kaiser MCRC Appeals Committee Review Compex Patient History 16 Legal
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
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)...
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
Patient Goals Payment Dispute Kaiser UCSF Continue Effective Treatme
FQ0401 - ..
FQ0402 - Millie's Objective Continue Care at UCSF Resolve Payment Problems
FQ0404 - Follow up ref SDS 19 T94H.
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
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
Kaiser Referral UCSF Treatment Clinical Trial Patient Did Not Self-r
GD0401 - ..
GD0402 - Kaiser Presented Millie Treatment at UCSF Patient Did Not Self-refer
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.
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
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.
Coinsurance 20% Self-referral EOC Section 7 Clinical Trials Not Appl
H40401 - ..
H40402 - Continuing Condition Requires Continuing Care by Kaiser
H40403 - EOC Applied Millie's Patient History Clinical Trials No Coinsurance
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
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
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.
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
UCSF Justification Charges Financial Engineering Resolve Billing Irr
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
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...
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
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....
I60465 - a. What rates are being charged relative to the statute?
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?
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
UCSF Duplicate Billings Doctor Visits Pink Invoices Justification Ch
JE0401 - ..
JE0402 - $20K Additional Annual Charges for Millie's Treatment at UCSF
JE0403 - New Billings Doctor Visits Appear Duplication Prior Payments
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.
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?
JE0470 - [On 071010 Millie requests clarification of billings from
JE0471 - multiple business units at UCSF. ref SDS 31 HZ6S
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
JE0510 - ..
JE08 - 1711
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.