UCSF Medical Center
Patient Financial Services
PO Box 0810
2300 Harrison Street
San Francisco, CA
415 353 3700


September 12, 2007

08 02 04 60 07091201



Millie

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Subject:   Billings Payments Clinical Trial

Thank you for making the recent facility account payments.
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Your facility accounts have been reviewed by UCSF's Manager for Medicare billing. He made a number of adjustments, resulting in your Patient responsibility being lowered.
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I am attaching a revised spreadsheet that reflects your recent payments & adjustments UCSF has made to your accounts. The amount you are responsible for is the coinsurance, which I have highlighted. There are several accounts that we are still waiting for a response from Medicare.
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I have also attached part of the Medicare Manual that states Managed care enrollees are liable for the co-insurance amounts applicable to services paid under Medicare fee for service rules. I have paperclipped & highlighted subsection 69.9 of the manual that explains this.
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You & Mr. Welch are welcome to contact me regarding any UCSF Medical Center facility billing.
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I hope you had a pleasant time on your vacation.

Regards,





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UCSF Facility Billing Milldred Buck, MRN 45772381 Date: September 12, 2007

<--------- UCSF Services -----------> <------- Medicare Payments ------> <---------------- Patient -------------------> Account Date Type Charges Date Payment Adjustment Coinsurance NC Svc Payments Date
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12571560 2007 01 30 OOV $101.00 2007 07 24 $111.54 -$38.42 $27.88 $27.88 2007 09 06 12575680 2007 02 01 OTX $2,997.00 2007 08 09 $752.12 $1,314.86 $188.02 $722.00 $0.00 12575738 2007 02 01 OOV $101.00 2007 07 24 $89.02 -$10.28 $22.26 $22.26 2007 09 06 12575761 2007 03 01 OOV $101.00 2007 07 24 $89.02 -$10.28 $22.26 $22.26 2007 09 06 12575768 2007 03 08 OOV $0.00 $0.00 12588856 2007 02 08 OOV $101.00 2007 07 24 $111.54 -$38.42 $27.88 $27.88 2007 09 06 12593370 2007 03 01 OTX $4,549.49 2007 08 09 $1,776.54 $1,531.99 $202.65 $1,028.31 $0.00 12652072 2007 02 22 OOV $101.00 2007 07 24 $89.02 -$10.28 $22.26 $0.00 12720616 2007 03 15 OOV $101.00 2007 07 24 $111.54 -$38.42 $27.88 $27.88 2007 09 06 12762558 2007 03 29 OOV $101.00 2007 07 24 $111.54 -$38.42 $27.88 $27.88 2007 09 06 12762597 2007 04 26 OOV $1,049. 2007 07 31 $569.74 $323.78 $22.26 $133.81 $22.26 2007 09 06 12762609 2007 05 10 OOV $101.00 2007 07 24 $111.54 -$38.42 $27.88 $27.88 2007 09 06 12762615 2007 05 24 OOV $1,094.59 2007 08 09 $658.03 $341.35 $27.88 $67.83 $27.88 2007 09 06 12762673 2007 04 12 OOV $0.00 $0.00 12763636 2007 04 05 OTX $2,114.32 2007 08 08 $698.82 $983.38 $162.12 $270.00 $0.00 12764302 2007 05 03 OTX $3,342.32 2007 07 27 $1,186.24 $1,872.12 $283.96 $0.00 12880922 2007 04 19 OOV $315.07 2007 07 24 $125.96 $161.23 $27.88 $27.88 2007 09 06 12997805 2007 07 19 OOV $101.00 $0.00 12997818 2007 08 02 OOV $101.00 $0.00 12997853 2007 06 07 OOV $101.00 2007 07 24 $111.54 -$38.42 $27.88 $27.88 2007 09 06 12997859 2007 06 21 OOV $1,049.59 2007 08 09 $143.72 $749.80 $22.26 $133.81 $22.26 2007 09 06 12997886 2007 06 07 OTX $3,489.59 2007 08 08 $821.70 $1,625.77 $162.12 $880.00 $0.00 12997900 2007 07 05 OTX $3,103.00 2007 08 30 $1,212.82 $1,572.73 $173.39 $144.52 $0.00 12997919 2007 08 02 OTX $4,338.09 $0.00 13171190 2007 07 12 OOV $0.00 $0.00 12363984 2007 08 16 OOV $81.00 $0.00 13284510 2007 09 06 OTX $565.00 $0.00 13284530 2007 10 04 OTX $0.00 $0.00
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Totals $29,199.65 $8,881.99 $10,215.65 $1,506.60 $3,380.28 $312.08

Patient payment on account pending justification from UCSF...................................................... -$312.08

UCSF claim for coinsurance.................................................. $1,194.52