CONTACTS 

SUBJECTS
Kaiser Regional Appeals Committee Hearing  Rspond MCRC Letter 071006

0603 -
0603 -    ..
0604 - Summary/Objective
0605 -
060501 - Follow up ref SDS 44 0000. ref SDS 43 0000.
060502 -
060503 -
060504 -
060505 -
060506 -
060508 -  ..
0606 -
0607 -
0608 - Progress
0609 -
060901 - Kaiser Used 071002 Letter to CMS to Construct Millie's Appeal
060902 -
060903 - Follow up ref SDS 44 TH8L, ref SDS 43 GM7M.
060904 -
060905 - On 071030 Paula called and advised that she investigated and confirmed
060906 - Kaiser ordered Millie's treatment at UCSF. ref SDS 44 5435
060908 -  ..
060909 - Paula explained on 071030 that Kaiser constructed an appeal on
060910 - Millie's behalf based on 50 pages of documents Kaiser received from
060911 - CMS, ref SDS 44 E64H, which CMS printed from Millie's patient history
060912 - drawn from links in a letter to CMS dated 070102. ref SDS 23 OY4Q
060914 -  ..
060915 - At that time, on 071030 Paula contacted UCSF and requested billing
060916 - information. ref SDS 44 FM95  In the afternoon, Millie received a
060917 - letter from UCSF confirming that Kaiser had requested information on
060918 - paying UCSF billings for Millie's care. ref SDS 44 WZ5J
060920 -  ..
060921 - The next day, on 071031 Millie received notices that UCSF planned
060922 - assigning to a collection agency for recovery of $265.02, ref SDS 46
060923 - TH8L, and further planned to terminate Millie's treatment at UCSF for
060924 - cancer because Kaiser has not paid the bills. ref SDS 46 KM4J  In the
060925 - call, Paula requested copies of these letters to from UCSF.
060927 -  ..
060928 - Submitted letter to Paula with copies to UCSF
060929 -
060930 -    1.  Subject: **** Account Kaiser Payment UCSF Documentation
060931 -        Date: Mon, 05 Nov 2007 23:31:51 -0800
060936 -         ..
060937 -    2.  Paula,
060939 -         ..
060940 -    3.  This confirms our telecon this afternoon.
060942 -         ..
060943 -    4.  You have not received Doctor's notes from UCSF showing work
060944 -        performed on Kaiser's referral for Millie's treatment beginning
060945 -        on 070130.  [discussed with Paula on 071030, ref SDS 44 FM95,
060946 -        and again the next day on 071031. ref SDS 45 NT3J]  Hopefully
060947 -        UCSF will submit this information to Kaiser within the next few
060948 -        days to expedite your work. [reflecting UCSF letter to Millie
060949 -        on 071030, ref SDS 44 WZ5J]  UCSF has indicated urgency about
060950 -        payments. [UCSF letter on 071026 demanding payment in 1 week,
060951 -        ref SDS 39 SU5V, UCSF claims on 071029 suffering from stringing
060952 -        out payments, ref SDS 43 6N6K; On 071031 Millie receives notice
060953 -        dated 071026 UCSF has scheduled assignment to a collection
060954 -        agency for payment of account 12493370 in the amount of
060955 -        $202.65, ref SDS 46 KK4I, reviewed on 070830, ref SDS 16 4P8K,
060956 -        and revised again on 070917, ref SDS 20 MK4H; there is no
060957 -        indication of UCSF collection efforts against Kaiser who
060958 -        ordered the work; and in a separate notice the next day on
060959 -        071027 UCSF threatens that Millie's treatment for cancer
060960 -        ordered on referral by Kaiser will be terminated if UCSF does
060961 -        not receive payment from Millie, which is owed by Kaiser.
060962 -        ref SDS 46 KM8J]  By copy I am reminding UCSF about pending
060963 -        documents you need.
060965 -         ..
060966 -    5.  You clarified today that Kaiser does not require medical
060967 -        records consisting of Nurse's Notes on Millie's treatment in
060968 -        the Infusion Clinic. [requested on 071031, ref SDS 45 NT3J]  By
060969 -        copy to UCSF this confirms a change from requirements discussed
060970 -        on 071030, greatly reducing the level of effort and expense for
060971 -        UCSF. ref SDS 44 JA4S
060973 -         ..
060974 -    6.  You have not yet received billing information from UCSF, but
060975 -        understand that this is being assembled, as noted in a letter
060976 -        from UCSF on 071030. ref SDS 44 WZ5J [following review earlier
060977 -        on 071030 finding partial and conflicting information in
060978 -        Kaiser's computers and documents received from UCSF,
060979 -        ref SDS 44 FM6N, leading to a decision that Kaiser would
060980 -        contact UCSF to obtain information required to determine
060981 -        payments owed for Millie's care on referral. ref SDS 44 FM95]
060982 -
060983 -           [On 071114 Paula reported continuing partial and conflicting
060984 -           information from UCSF and in Kaiser's computer on case
060985 -           management needed to evaluate payment of UCSF charges for
060986 -           Millie's treatment. ref SDS 48 NE5P
060988 -            ..
060989 -           [On 071116 Paula reports Kaiser has not received documents
060990 -           requested from UCSF. ref SDS 49 ET8H
060992 -            ..
060993 -           [On 071126 Paula reports again that Kaiser has not received
060994 -           doucments requested from UCSF to substantiate charges for
060995 -           Millie's treatment, ref SDS 50 H66X; patient provided
060996 -           records showing scope of care by UCSF that supports payment
060997 -           of charges for treatment. ref SDS 50 OS4N
060999 -         ..
061000 -    7.  Additionally, you have not heard from Nancy Baird at UCSF,
061001 -        following up her call to me last week on 071101 and indicating
061002 -        that she would call you to coordinate on what Kaiser needs from
061003 -        her MGBS group in order to pay UCSF for professional services.
061004 -        ref SDS 47 1N7Y
061006 -         ..
061007 -    8.  During our call, you commented that Nancy's group may be
061008 -        sending billings to Kaiser's Medicare unit, and then would
061009 -        submit charges to Kaiser.  This raises concern about delaying
061010 -        dispute resolution, and payment to UCSF.  In a telephone call
061011 -        the morning of 071029 UCSF objected to delays that "string out"
061012 -        payments. ref SDS 43 6N6K [also cited above, ref SDS 0 K36X,
061013 -        and reflecting UCSF demand on 071026 for payment in 1 week.
061014 -        ref SDS 39 SU5V, and further reflecting notice of terminating
061015 -        treatment for cancer without payment of 202.65, received on
061016 -        071031. ref SDS 46 KM8J]
061018 -         ..
061019 -    9.  Later in the day, on 071030 UCSF submitted a letter saying to
061020 -        disregard complaints on delayed payments, since you apparently
061021 -        called and told UCSF that your department is looking into this
061022 -        issue. ref SDS 44 WZ5J
061023 -
061025 -         ..
061026 -        Kaiser Notified UCSF Plans Terminate Referral Treatment
061027 -
061028 -   10.  In our call today, you requested copies of letters Millie
061029 -        received from UCSF the next day 071031.  UCSF presented plans
061030 -        in a letter dated 071026 to assign for collection agency
061031 -        support recovery of $202.65. ref SDS 46 NV6N
061033 -         ..
061034 -   11.  A second UCSF letter dated 071027 disclosed plans to terminate
061035 -        treatment without payment of $202.65. ref SDS 46 KM4J
061036 -
061037 -           [On 071128 Kaiser Appeals Committee approved payment for
061038 -           Millie's care on referral to UCSF. ref SDS 51 JZ5R
061040 -         ..
061041 -   12.  In a meeting at Kaiser on 070921 the doctor advised that
061042 -        continuing Millie's treatment with cetuximab, which has proved
061043 -        very effective at UCSF, would be much more expensive for
061044 -        Kaiser. ref SDS 21 CU58
061046 -         ..
061047 -   13.  Additionally, the doctor's treatment plan at Kaiser calls for
061048 -        UCSF to add carboplatin if disease progresses, which currently
061049 -        has heightened concern with recent rise of the cancer marker.
061050 -        The Appeals Committee should consider carefully the treatment
061051 -        plan in the medical chart, reported on 070921. ref SDS 21 WF8P
061053 -         ..
061054 -   14.  Can you please coordinate with UCSF to determine if their
061055 -        letter the day before on 071030 saying to disregard demands for
061056 -        immediate payment, applies to collection efforts in their
061057 -        letters dated 071026, and 071027?  This would provide breathing
061058 -        room for the Appeals Committee to deliberate without
061059 -        distraction of collection activities.
061060 -
061061 -            [On 071126 Paula reports again that Kaiser has not received
061062 -            doucments requested from UCSF to substantiate charges for
061063 -            Millie's treatment, ref SDS 50 H66X; patient provided
061064 -            records showing scope of care by UCSF that supports payment
061065 -            of charges for treatment. ref SDS 50 OS4N
061067 -             ..
061068 -            [On 071128 Kaiser Appeals Committee approved payment for
061069 -            Millie's care on referral to UCSF. ref SDS 51 JZ5R
061070 -
061072 -         ..
061073 -        Appeals Committee Procedures
061074 -
061075 -   15.  During our call, you seemed to describe plans for expedited
061076 -        review, and that the Appeals committee consists of 15 (13??)
061077 -        people drawn from the ranks of medical managers in the Oakland
061078 -        office.  Some members of the committee may have been practicing
061079 -        physicians, but Appeals review is now their primary assignment.
061081 -         ..
061082 -   16.  You seemed further to indicate that the packet of documents you
061083 -        assemble and submit to each of the 15 committee members is the
061084 -        only information they will have in making a determination.
061085 -        Apparently there will be an actual meeting to consider Millie's
061086 -        case.  Our discussion today sounded like your boss, or whoever
061087 -        heads up your group, will travel to Oakland to explain the case
061088 -        to the Appeals Committee.  You indicated in our call that this
061089 -        person is very familiar with Millie's case.
061091 -  ..
061092 - On 071010 developed list of questions on Kaiser Appeals Committee
061093 - procedures. ref SDS 31 4V7H
061094 -
061095 -            [On 071128 Kaiser Appeals Committee approved payment for
061096 -            Millie's care on referral to UCSF. ref SDS 51 JZ5R
061098 -  ..
061099 - Letter to Paula at Kaiser MCRD unit continues...
061100 -
061101 -   17.  Ordinarily a hearing or meeting leading to a determination that
061102 -        affects patient interests should afford the patient opportunity
061103 -        to review and supplement the record to avoid errors and
061104 -        omissions.  Your letter dated 071006 [and received on 071010]
061105 -        said Millie should send any additional information to you that
061106 -        will assist the Appeals Committee. ref SDS 31 R16K  This
061107 -        requires notice by Kaiser of what is being presented to the
061108 -        Committee.  At this time, Millie has no idea what you have seen
061109 -        and assembled.
061110 -
061111 -
061113 -         ..
061114 -        Doctor/Patient Partnership Make Sense Complex Patient History
061115 -        Patient History Complex Collaborate Doctor/Patient Partnership
061116 -
061117 -   18.  You indicated today that your office does not disclose to the
061118 -        patient information assembled by the case manager.  You also
061119 -        commented today that patient history in this case is long and
061120 -        complex as a result of six (6) years getting excellent care
061121 -        from Kaiser. Therefore figuring out what information to provide
061122 -        the Appeals Committee that will help avoid mistakes takes time.
061124 -         ..
061125 -   19.  Kaiser champions a "doctor/patient partnership" as the most
061126 -        effective solution for "team care" practice, see review on
061127 -        990625. ref SDS 2 4185
061129 -         ..
061130 -   20.  This can be implemented to provide common understanding on
061131 -        patient history even if there is disagreement on applicable
061132 -        law.  Since patient history is very complex, we should work
061133 -        together to assemble a useful packet for the Appeals Committee
061134 -        and brief your manager or whoever presents the case to the
061135 -        Appeals Committee.  In that case, there is no reason for the
061136 -        patient to make an appearance, especially since you indicated
061137 -        this is only a 10 minute phone call.  I would be happy to drive
061138 -        down to your office in Pleasanton to see what you have and
061139 -        assist in arranging an effective chronology on issues to be
061140 -        determined.  This would save time and increase accuracy.
061142 -             ..
061143 -            [On 071126 Paula called for assistance finding patient
061144 -            history which Kaiser has been unable to find in Kaiser's
061145 -            records, and has been unable to get from UCSF. ref SDS 50
061146 -            H68Y
061147 -
061149 -         ..
061150 -        Case Record Disclose to Patient Prepare Appeal Committee Hearing
061151 -
061152 -   21.  Alternatively, Kaiser should provide to the patient the case
061153 -        packet which you assemble, and allow 10 days for comments to be
061154 -        incorporated into the packet given to the Appeals Committee
061155 -        members.
061157 -         ..
061158 -   22.  The reason for increased discloser in this case is because
061159 -        Kaiser has not yet told the patient what has been reviewed by
061160 -        your team.  You reported in our telephone call on 071006 that
061161 -        you received the letter to CMS on 071002, along with 50 pages
061162 -        of faxed documents. ref SDS 26 Z87L  While we know the content
061163 -        of the document sent to CMS on 071002, we have no way of
061164 -        knowing what documents Jullin Kwok and her colleagues at CMS
061165 -        decided to fax to you.  You also noted today that you have
061166 -        access to Millie's entire patient history, which covers
061167 -        thousands of pages.  Under the doctor/patient partnership
061168 -        model, you should be able to draw on support of patient
061169 -        assistance which is more familiar with case history and can
061170 -        assemble case studies with technology that manages issues,
061171 -        i.e., various subjects.
061172 -
061173 -            [On 071026 Kaiser reported having lost the document dated
061174 -            071002 received from CMS, and requested another copy from
061175 -            the patient. ref SDS 50 H68Y
061176 -
061178 -         ..
061179 -        IBC Diagnosis Patient History Case Study Biopsy
061180 -
061181 -   23.  For example, during our call today you asked about Millie's
061182 -        cancer, and when she was diagnosed with IBC.  [The primary care
061183 -        physician] Doctor ******* has the most accurate information.
061184 -        Understandings from meeting with the doctor and review of test
061185 -        records indicate Millie has secondary IBC, and is being treated
061186 -        at UCSF for a 3rd relapse.
061188 -         ..
061189 -   24.  Case study on discovery of IBC is listed on 040517, ref SDS 6
061190 -        S66O, showing a biopsy on 040419 and received from Kaiser on
061191 -        040517 diagnosed IBC. ref SDS 6 YN3L
061192 -
061193 -
061195 -         ..
061196 -        EOC Senior Advantage Requires Kaiser Pay for Patient Care
061197 -
061198 -   25.  You mentioned today the Appeals Committee will base the
061199 -        determination on EOC requirements.  Kaiser's Senior Advantage
061200 -        EOC was reviewed on 070927.  Section 2 requires the doctor to
061201 -        prescribe treatment needed for covered services, in this case
061202 -        "oncology". ref SDS 22 WS6M
061204 -         ..
061205 -   26.  Review of EOC Section 7 says patients can self-refer for
061206 -        treatment in clinical trials, and in that case costs are paid
061207 -        by Medicare and the patient, rather than by Kaiser. ref SDS 22
061208 -        1F67
061210 -         ..
061211 -   27.  Since Millie did not self-refer, Kaiser retains responsibility
061212 -        for her care including costs, as further explained reviewing 16
061213 -        issues in this case, also, listed on 070927. ref SDS 22 WU6M,
061214 -        and citing analysis from meeting at UCSF on 070830. ref SDS 16
061215 -        QX5K
061216 -
061217 -            [On 071128 Kaiser Appeals Committee approved payment for
061218 -            Millie's care on referral to UCSF. ref SDS 51 JZ5R
061220 -         ..
061221 -   28.  Please consider the partnership model in deciding what issues
061222 -        to present, and relevant factual background from patient
061223 -        history. The medical people have done a wonderful job treating
061224 -        Millie; billings and disputes deserve comparable effort.
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