CONTACTS 

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0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 16 0000.
040502 -
040503 -
040504 -
040506 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - This morning Glenna called and advised that UCSF has not received
040902 - authorization for Millie's treatment, contrary to representations on
040903 - 081103 that Kaiser has submitted the authorization. ref SDS 16 ZX8F
040905 -  ..
040906 - Called and talked to Sonia at N&P. ref SDS 16 4P8E
040908 -  ..
040909 - Millie received a letter from Sonia with initial ideas on supporting
040910 - entitlement to Kaiser's support for treatment on referral to UCSF.
040911 - ref SDS 16 XL4K
040913 -  ..
040914 - Millie submitted a letter summarizing background to assist Sonia
040915 - finding support targeted to issues in dispute...
040916 -
040917 -    1.  Subject: Kaiser Referral Clinical Trials for Medicare Patient
040918 -        Date: Wed, 12 Nov 2008 14:41:01 -0800
040925 -         ..
040926 -    3.  Thanks for taking time to talk to Rod this morning [reported in
040927 -        another record today on 081112, ref SDS 16 4P8E, and confirmed
040928 -        in Sonia's letter also received today on 081112, ref SDS 16
040929 -        XL4K].  My minds in whirl with everything happening all at
040930 -        once.  You asked Rod for background on my situation...
040932 -         ..
040933 -    4.  Briefly, [on 070105] my doctor at Kaiser referred me to UCSF
040934 -        for treatment in a clinical trial, ref SDS 2 PK68, [and citing
040935 -        agreement between Kaiser and UCSF on 061230 for Kaiser to pay
040936 -        for all costs not paid by the clinical study, ref SDS 1 3X6K],
040937 -        which began Feb 1, 2007. ref SDS 3 0001
040939 -         ..
040940 -        About 6 months later, I began getting bills from UCSF [shown on
040941 -        070823, ref SDS 4 X16N], who claimed Kaiser refused payment on
040942 -        the grounds that Medicare patients must "self-refer" for
040943 -        treatment in clinical trials [reported from meeting at UCSF on
040944 -        070830, ref SDS 5 IR4F].  I disputed this [shown in analysis on
040945 -        070927, ref SDS 6 WU6M].  You helped investigate the issue at
040946 -        that time [e.g., on 071022, ref SDS 7 3P4L, and telecon on
040947 -        071024. ref SDS 8 HE96].  On Nov 30, 2007, Kaiser issued a
040948 -        determination by the Regional Appeals Committee that Kaiser
040949 -        would honor the doctor's referral [reported on 071128,
040950 -        ref SDS 9 TH8L].  They have paid the bills up until now.
040952 -         ..
040953 -    5.  During a meeting at Kaiser on Aug 29, 2008, my doctor
040954 -        determined cancer was progressing, ref SDS 10 RP8T, and advised
040955 -        me to have UCSF prescribe another treatment, because he was
040956 -        unable to provide effective care (we have gone through all the
040957 -        standard treatments) and he would authorize continuing payment
040958 -        as for the prior regimen. ref SDS 10 RP9R
040960 -         ..
040961 -    6.  On October 16th Doctor Rugo at UCSF implemented Kaiser's
040962 -        referral and prescribed treatment for me with sunitinib
040963 -        clinical trial, ref SDS 11 J38U, scheduled to begin tomorrow on
040964 -        Nov 13th.  UCSF and Kaiser collaborated on the referral, with
040965 -        Kaiser performing tests this past week required for me to begin
040966 -        treatment. [see Millie's letter to the medical team on 081111.
040967 -        ref SDS 15 WP8G]
040969 -         ..
040970 -    7.  On Monday UCSF called and advised that my doctor at Kaiser
040971 -        signed authorization for my care at UCSF. [reported on 081031,
040972 -        ref SDS 13 5C7J, confirmed by UCSF letter. ref SDS 14 458L]
040974 -         ..
040975 -    8.  This morning, UCSF called back and said Kaiser has refused to
040976 -        submit the authorization issued by my doctor. ref SDS 16 ZX8F
040977 -        Since I have been without treatment for nearly a month, and
040978 -        cancer is spreading, timely treatment is essential. [Millie's
040979 -        last treatment for cancer was on 081023. ref SDS 12 V94O]
040981 -         ..
040982 -    9.  Rod called and talked to Paula McPhail [...reported today in
040983 -        another on 081112, ref SDS 16 PQ35], the case manager who
040984 -        issued Kaiser's letter on Nov 30, 2007 that approved payment
040985 -        for the prior treatment on clinical trial.
040987 -         ..
040988 -   10.  Paula referred us to a Kaiser unit for "Expedited Claims" (888
040989 -        987 7247), located in Oakland.  Paula indicated that if Kaiser
040990 -        denies relief under the expedited procedure, the matter will
040991 -        automatically be sent to her office for further review.  She
040992 -        would not necessarily be assigned this second claim.
040993 -        ref SDS 16 FR3N]
040995 -         ..
040996 -   11.  Rod called Kaiser Expedited Claims and got the ball rolling.
040997 -        Expect to hear back later today. ref SDS 16 4Q7B
040998 -
040999 -            [...in another record earlier today on 081112, Expedited
041000 -            Claims denied relief for Millie's from Kaiser's failure to
041001 -            perform the doctor's order issued on 081103 for Millie's
041002 -            treatment at UCSF, and refused to carry out the doctor's
041003 -            authorization for payment of Millie's treatment for cancer.
041004 -            ref SDS 16 P28U
041006 -             ..
041007 -            [...in another record earlier today on 081112, Expedited
041008 -            Claims Department advised that Kaiser must implement the
041009 -            doctor's order for treatment. ref SDS 16 PR35
041011 -             ..
041012 -            [...in another record later today on 081112, Millie
041013 -            received a letter from Sonia asking about results of
041014 -            Expedited Claims review. ref SDS 17 IJ9F
041016 -         ..
041017 -   12.  The case boils down to Kaiser's duty to provide care [called
041018 -        out in EOC section 2, reviewed on 070927, ref SDS 6 WS6M, see
041019 -        as well Kaiser's pattern and practice using clinical trials for
041020 -        primary care treatment, ref SDS 6 EY8J], and whether they can
041021 -        avoid the cost of care by referring the patient to a clinical
041022 -        trial, then claim the patient "self-referred" [see theories of
041023 -        recovery on 070927, ref SDS 6 WU6M].
041025 -         ..
041026 -   13.  I expected there would be a lot of lawyers familiar with this
041027 -        issue.  It turns I can't find anyone.  That may reflect the
041028 -        fact that the law has not changed for about 10 years.  Kaiser
041029 -        always before paid for referrals.  Only in the past 2 years did
041030 -        they come up with the Medicare "self-referral" approach.
041032 -         ..
041033 -   14.  Sorry for such a long winded explanation.  Background on Sep
041034 -        27, 2007 for the prior claim lists specific issues with
041035 -        citations to statutes and Kaiser "Evidence of Coverage"
041036 -        language. ref SDS 6 8G5N
041038 -         ..
041039 -   15.  I appreciate very much your time, and understand if you cannot
041040 -        help.
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