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0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 8 0000, ref SDS 7 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Millie submitted a letter responding to the letter from UCSF received
040902 - yesterday on 071009. ref SDS 9 X65I
040903 -
040904 -            [...below, UCSF responds. ref SDS 0 925L
040905 -
040906 -    1.  Subject:  Coinsurance Payment
040907 -        Date:  Wed, 10 Oct 2007 12:41:58 -0700
040920 -         ..
040921 -    2.  Tomorrow, I will pay $1,194.52 at the Business Office on the
040922 -        ground floor at UCSF 1600 Division Street, as you instructed
040923 -        for the prior payment on September 6th. ref SDS 3 EB3P
040925 -         ..
040926 -    3.  Please let me know if I can do this by credit card, or if you
040927 -        require a check.  Credit card works better for me.
040929 -         ..
040930 -    4.  This pays UCSF's claim for items listed in your letter received
040931 -        yesterday on 071009, ref SDS 9 N88X, which restates amounts in
040932 -        the revised spreadsheet attached to your letter on September
040933 -        12, 2007, and which was received and reviewed in the record on
040934 -        September 17. ref SDS 4 WP5I
040936 -         ..
040937 -    5.  Payment is not agreement that I owe coinsurance for this
040938 -        transaction.  I was never informed I would owe coinsurance.
040939 -        Until August, no one at Kaiser nor UCSF had ever mentioned
040940 -        coinsurance nor copayments.  I am shocked by this experience,
040941 -        but committed to pay whatever I owe.
040943 -         ..
040944 -    6.  Kaiser and CMS are reviewing application of coinsurance in this
040945 -        case.  Jullin Kwok who manages the Medicare contract with
040946 -        Kaiser for Senior Advantage advised yesterday that she has
040947 -        submitted the question for administrative review. ref SDS 8
040948 -        EX5J  CMS indicated this issue has not come up often, so
040949 -        requirements are hazy.  Jullin indicated her impression that
040950 -        clinical trial treatments are per se "self-referrals."  This
040951 -        might mean Medicare law prohibits an HMO from paying for any
040952 -        costs not covered by the clinical trial, which conflicts with
040953 -        UCSF and Kaiser correspondence in this case on December 30,
040954 -        2006.  Jullin further stated that her office has not previously
040955 -        considered the many issues presented in this case, and so she
040956 -        has requested guidance.  Similarly, Paula McPhail in Kaiser's
040957 -        MCRC unit is reviewing their responsibility, as shown in the
040958 -        record on 071006. ref SDS 6 0000
040960 -         ..
040961 -    7.  Work in progress to resolve complex billing issues deserves
040962 -        UCSF support.  Research on Medicare rules indicates the
040963 -        clinical trial service provider should explain charges. [see
040964 -        070829, ref SDS 1 SF52, and on 070917, ref SDS 4 416K]  As,
040965 -        well, UCSF deserves payment for excellent services.  Payment
040966 -        today allows time for thorough review.  In turn, I would like
040967 -        the following explanation of charges from UCSF...
040968 -
040969 -               [...below, UCSF refuses to explain billing charges, and
040970 -               refers customer to 3rd party. ref SDS 0 OY7O
040972 -             ..
040973 -        1.  Please state services included for invoice 12593370
040974 -            covering admission date March 1, 2007 and billed by UCSF on
040975 -            August 23, 2007.  UCSF lists some 100 separate charges in
040976 -            this document, and shows a line that says "Denied
040977 -            co-insurance" amount "$202.65". ref SDS 2 WO8I
040979 -             ..
040980 -            This is the same amount in your letter yesterday claiming
040981 -            entitlement to payment, and which I am including with
040982 -            payment tomorrow.
040984 -             ..
040985 -            Is coinsurance calculated against all the 100 line items in
040986 -            the invoice?  What items are added together to produce the
040987 -            total for calculating coinsurance?  What is the coinsurance
040988 -            rate that then produces the billing charge of $202.65?
040989 -
040990 -               [...below, UCSF refuses to explain billing charges, and
040991 -               refers customer to 3rd party. ref SDS 0 OH7R
040993 -             ..
040994 -        2.  Please explain variance in billings for services that are
040995 -            constant.  I get the same treatment every week.  I see the
040996 -            doctor  and her team, in the beginning twice a month, and
040997 -            since September this has been reduced to just once a month.
040998 -            We should be able to settle on at least a general
040999 -            understanding of how much I owe for repetitive work.
041000 -
041001 -               [...below, UCSF does explain why charges are not the
041002 -               same for same services each month. ref SDS 0 OH83
041003 -
041004 -
041006 -             ..
041007 -            Clinical Trial Funded Pays for Certain Costs
041008 -
041009 -        3.  What costs are paid by the clinical trial as noted in
041010 -            Doctor Rugo's letter to Kaiser on December 30, 2007?  I ask
041011 -            this because when I go in for meetings, there is a big sign
041012 -            on the front desk that says to pay before seeing the
041013 -            doctor.  The check-in attendant tells me I don't owe
041014 -            copayments to meet with the doctor, because this is covered
041015 -            by the clinical trial. Therefore, I would like to know what
041016 -            the clinical trial pays and what is left over for which I
041017 -            owe coinsurance.  What about blood tests and chemotherapy,
041018 -            which are exhaustively listed throughout UCSF invoices.
041019 -            (see example listed on 070830. ref SDS 2 F94O)
041020 -
041021 -               [...below, UCSF refuses to explain costs paid by
041022 -               clinical trial which are not subject to coinsurance
041023 -               charges to the customer. ref SDS 0 OY7O
041024 -
041026 -             ..
041027 -            Total UCSF Billing Moving Target New Charges Doctor Services
041028 -
041029 -
041030 -        4.  UCSF letter received yesterday, shown below, seems to
041031 -            present the total UCSF claim for coinsurance on UCSF
041032 -            services is $1,194.52 from inception on January 30, 2007,
041033 -            through the end date of July 5, 2007?  Please confirm this
041034 -            is a correct understanding, or otherwise submit any and all
041035 -            additional charges for this period.  I need to know the
041036 -            total UCSF is claiming through a specific period.
041038 -  ..
041039 - On 070830 UCSF submitted during a meeting a spreadsheet showing total
041040 - amount owed. ref SDS 2 OT8M
041042 -  ..
041043 - Millie's letter to UCSF continues...
041044 -
041045 -            As noted in discussions with Kaiser on Saturday, October
041046 -            6th, I received that same day a four (4) page invoice from
041047 -            UCSF #45772381 dated October 3, 2007 and in the amount of
041048 -            $2,2264.00.  This is the total of a series of charges
041049 -            dating from January 30, 2007, the date I first met with the
041050 -            medical team at UCSF and extends only through April 19,
041051 -            2007.  The invoice lists Doctor Rugo's name, Doctor Benz,
041052 -            and Doctor Johnson at Kaiser, so I am totally confused.
041053 -            ref SDS 6 PRWW
041055 -             ..
041056 -            This raises a question of whether your letter yesterday is
041057 -            the total I owe.  Are there other charges for the period
041058 -            from April 19th through today, etc?
041059 -
041060 -                [...below Bob reports another UCSF business unit uses
041061 -                pink invoices; UCSF is making a review and will notify
041062 -                Millie of the total being claimed by UCSF for recovery
041063 -                from Millie for clinical trial services. ref SDS 0 OH89
041065 -                 ..
041066 -                [On 071011 Millie's letter asks about other colored
041067 -                invoices still pending from UCSF, and requests clarity
041068 -                on total claimed by UCSF for clinical trial services.
041069 -                ref SDS 10 K65S
041071 -                 ..
041072 -                [On 071024 letter to UCSF asks about progress on
041073 -                Millie's requests on 071010, and again today clarifying
041074 -                billing procedures, and the total amount owed by all
041075 -                business units for Millie's treatment in clinical
041076 -                trials. ref SDS 11 EP4T
041077 -
041079 -             ..
041080 -            Pink Invoices Duplicate Charges Doctor Services
041081 -
041082 -            This new invoice is different in appearance (e.g., pink,
041083 -            rather than white).  The format is markedly different from
041084 -            prior UCSF invoices, and so suggests possibly a different
041085 -            business unit is billing for additional charges.  Can you
041086 -            please clarify what is intended?  Should I ignore this new
041087 -            invoice as a duplication of charges for doctor visits
041088 -            already listed in your earlier invoices, and which are
041089 -            included in charges listed in your letter yesterday, shown
041090 -            below?
041092 -         ..
041093 -    8.  Thanks for your continued efforts to resolve billing problems.
041094 -        Please let me know if I can pay by credit card tomorrow.
041095 -
041096 -
041098 -  ..
0411 -
0412 -
0413 - 1813
0414 -
041401 - Millie received a letter from Bob responding to Mil's letter to UCSF
041402 - earlier this afternoon, per above. ref SDS 0 UW5J
041403 -
041404 -     [On 071011 Millie responded to UCSF's letter today. ref SDS 10
041405 -     UW5J
041407 -  ..
041408 - Bob says to Millie...
041409 -
041410 -    1.  Subject: FW: Coinsurance Payment
041411 -        Date: Wed, 10 Oct 2007 16:05:52 -0700
041420 -         ..
041421 -    2.  I have reviewed your UCSF facility accounts & have two accounts
041422 -        that need to be added to the total that is now patient
041423 -        responsibility:
041425 -         ..
041426 -    3.  account number:        12997919          12652072
041427 -        date of service:       08/02/2007        02/22/2007
041428 -        total charges          $4,338.09         $101.00
041429 -        patient liability      $  202.65         $ 22.26
041431 -         ..
041432 -    4.  This will bring your current facility patient responsibility to
041433 -        $1,237.03.
041435 -         ..
041436 -    5.  You currently have five facility accounts that we are in the
041437 -        process of billing Medicare:
041438 -
041439 -          account number:  12997818   13263984   13284510   13400055      13284530
041440 -          date of service: 08/02/2007 08/16/2007 09/06/2007 09/20/2007    10/04/2007
041441 -          total charges:   $101.00    $81.00     $1,734.00  $1,026.51     $512.00
041443 -         ..
041444 -    6.  We will request payment on these five account once Medicare has
041445 -        paid & established your financial liability, if any.
041447 -         ..
041448 -    7.  Any future medical services at UCSF will result in additional
041449 -        accounts being established.
041451 -         ..
041452 -    8.  We accept the following credit cards VISA, MASTERCARD, AMERICAN
041453 -        EXPRESS & DISCOVER.
041454 -
041456 -         ..
041457 -        UCSF Refuses Explain Charges Refers Patient to Medicare
041458 -
041459 -
041460 -    9.  Questions regarding how Medicare determines the amount of your
041461 -        co-insurance (re account # 12593370) should be addressed to
041462 -        Medicare.  That particular account was for lab & chemotherapy
041463 -        received on March 1st, March 15th, March 22nd & March 29th.
041465 -  ..
041466 - Does this mean UCSF cannot arrange a meeting with Kaiser's Medicare
041467 - folks to explain their work product?  What about transparency?  Does
041468 - this work go entirely unaudited?  What is the quality control element
041469 - to check for accuracy in this payment process?
041471 -  ..
041472 - UCSF refusal to explain charges for medical services requested by the
041473 - customer in Millie's letter earlier today conflicts with CMS guidance,
041474 - per above, ref SDS 0 HZ9X, and suggests irregularities in billing
041475 - procedures, cited in issue 13 developed on 070927. ref SDS 5 WW4O
041476 -
041477 -            [On 071011 Millie asks for name and contact information for
041478 -            person at Kaiser Medicare unit who is preparing charges on
041479 -            behalf of UCSF. ref SDS 10 K64W
041481 -  ..
041482 - UCSF explanation of charges for lab and chemotherapy does not address
041483 - patient's request for explanation of costs paid by the clinical trial,
041484 - per above, ref SDS 0 HZ5U, nor why the patient is charged for lab
041485 - expenses, when Kaiser reports that Medicare pays for blood tests,
041486 - reported on 070829, ref SDS 1 695L, and supported by Kaiser Senior
041487 - Advantage EOC Section 7 on page 68. ref SDS 5 1F67
041488 -
041490 -  ..
041491 - Blood Tests Not Charged 20% Coinsurance
041492 - 20% Coinsurance Not Charged on Laboratory Blood Tests
041493 -
041494 -
041495 - UCSF letter from Bob to Millie continues...
041496 -
041497 -   10.  Co-insurance is a percentage of the cost that is your portion
041498 -        to pay.  In general, the co-insurance is 20%, but there are
041499 -        some services, such as lab, that do not have a co-insurance.
041500 -        Co-payments are flat fees that may be charged for medical
041501 -        service, regardless of the cost.
041503 -  ..
041504 - UCSF evident representation that Millie does not owe coinsurance on
041505 - blood tests aligns with documentation from Kaiser on 070829 that says
041506 - Medicare pays lab costs for clinical trials. ref SDS 1 695L  On 070927
041507 - Kaiser EOC Section 7 says that laboratory blood tests are paid by
041508 - Medicare. ref SDS 5 1F67  UCSF refusal to submit explanation of
041509 - charges opens the prospect of irregularities in billings that require
041510 - review to establish actual amount owed, cited in issue #13 on 070927.
041511 - ref SDS 5 WW4O
041513 -  ..
041514 - UCSF letter from Bob to Millie continues...
041515 -
041516 -   11.  The reason for the variance in Co-insurance for office visits
041517 -        is that although the listed office charge is usually $101,
041518 -        there are codes that accompany the bill that reflect the level
041519 -        of service provided (level 4 is $22.26 & level 5 is $27.88.
041520 -        These levels are on the Itemized Statements that you receive.
041521 -
041522 -            [On 071011 Millie's letter asks UCSF why evident double
041523 -            billings for same level 4 and 5 services for same period
041524 -            previously paid. ref SDS 10 K65P
041526 -  ..
041527 - Explanation of level 4 and 5 charges appears to duplicate new pink
041528 - invoices from UCSF received on 071006. ref SDS 6 PRWW
041529 -
041531 -  ..
041532 - MGBS UCSF Multiple Billings Duplicate Payments by Medicare and Millie
041533 -
041534 - UCSF letter from Bob to Millie continues...
041535 -
041536 -        The Medical Group Business Service (MGBS) is responsible for
041537 -        billing any physician Pro Fees.  Their bills are printed on
041538 -        pink paper. I have asked the assistant manager of MGBS to
041539 -        review your accounts.  This information will be forwarded to
041540 -        you once it is received.
041542 -  ..
041543 - Bob seems to confirm UCSF has multiple business units making claims
041544 - against Millie for charges of medical services, responding to Millie's
041545 - letter to UCSF this morning, per above, ref SDS 0 HZ6S, citing prior
041546 - analysis on 071006. ref SDS 6 PRWW
041547 -
041548 -            [On 071011 Millie asks UCSF about other business units
041549 -            billing for clinical trial services which have not yet been
041550 -            explained to the customer? ref SDS 10 K64T
041552 -             ..
041553 -            [On 071011 Millie's letter asks UCSF why evident double
041554 -            billings for same level 4 and 5 services for same period
041555 -            previously paid. ref SDS 10 K65P
041557 -  ..
041558 - Bob further indicates that UCSF is making a review to answer Millie's
041559 - request for UCSF's total claim. ref SDS 0 H13Q
041560 -
041561 -            [On 071011 Millie's letter asks about other colored
041562 -            invoices still pending from UCSF, and requests clarity on
041563 -            total claimed by UCSF for clinical trial services.
041564 -            ref SDS 10 K65S
041566 -             ..
041567 -            [On 071024 letter to UCSF asks about progress on Millie's
041568 -            requests on 071010, and again today clarifying billing
041569 -            procedures, and the total amount owed by all business units
041570 -            for Millie's treatment in clinical trials. ref SDS 11 EP4T
041572 -             ..
041573 -            [On 071101 Nancy Baird with MGBS called to request
041574 -            assistance with billing for professional services; she
041575 -            plans to contact Paula about facilitating UCSF billings for
041576 -            referral from Kaiser. ref SDS 12 5R5H
041577 -
041578 -
041592 -
041593 -
041594 -
041595 -
041596 -
041597 -
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0417 -