Clinical Trials Managed Care Provider Makes Referral
Dear James,
Following our telecon yesterday, this issue arises from a patient enrolled in
Kaiser's Senior Advantage [managed care] program since approximately 2004, and
with Kaiser for 20+ years. Kaiser
describes Senior Advantage
as shown in the
record on 070927 (September 27, 2007), and with comments showing the plain
language is not dispositive...
..
(Note: this is a knowledge management environment; click on subsidiary links
only when you want to know more about an issue, e.g., a case study)
..
On 061230 (December 30, 2006), Kaiser made arrangements for UCSF to treat a
patient in a clinical trial determined by Kaiser to be the best course of care.
The patient made no self-referral, but merely followed the doctor's orders.
Kaiser agreed to pay UCSF
any costs not covered by the clinical trial.
..
A policy question is whether Kaiser is prevented from prescribing and paying
for treatments Kaiser determines medically essential and which it cannot
otherwise provide? Does CMS and Medicare recognize distinctions between
physician referral and patient "self-referral"?
..
Subsidiary question is whether the patient can rely on authority of the doctor
to prescribe treatments based on past pattern and practice, or may Kaiser lead
a patient into expensive treatment without notice, and then 6 months later
start demanding payments?
..
Not sure these issues are very elegantly presented. It is a little late and we
have to leave for San Francisco in a few hours for Millie's weekly treatments
at UCSF.
..
The
record on 070830 provides context
with several case studies on patient
history that may be helpful (this is a bit complex, showing for example mind
boggling invoices).
..
The most glaring question is how a patient sent for treatment with assurances
of no cost can wind up with a bill for "coinsurance" 8 months later for $10K
per year at 56% of amounts approved by Medicare?
..
Millie's specific concerns on
coinsurance
are listed on 070830.
..
There are few
lessons learned
that may be helpful...
..
Thanks for taking a look. Don't get lost in links. If the case seems
interesting, please call 925 680 8947 to discuss your ideas.