CONTACTS 
0201 - UCSF Medical Center
020101 - Mr. Robert Zvi Schwartz, MPH
020102 - Patient Financial Consultant
020104 - Patient Financial Services

SUBJECTS
UCSF Billings Clinical Trial Treatment Reduced 80% from $4300 Down t

4803 -
4803 -    ..
4804 - Summary/Objective
4805 -
480501 - Follow up ref SDS 13 0000, ref SDS 12 0000.
480502 -
480503 -
480504 -
480505 -
480506 -
480507 -
480508 -
480510 -  ..
4806 -
4807 -
4808 - Progress
4809 -
480901 - Billing 80% Reduction from $4,300 Down to $1,500 Annualizes $2,000
480902 - UCSF Substantial Progress Resolving Clinical Trial Payment Issues
480903 -
480905 -  ..
480906 - Millie received ref DRT 1 0001 a letter from Bob at UCSF dated 070912,
480907 - following up the letter to UCSF on 070909, ref SDS 13 XH5H, and
480908 - saying....
480909 -
480910 -    1.  Thank you for making the recent facility account payments.
480911 -        ref DRT 1 0001
480913 -  ..
480914 - On 070906 Millie submitted interim payment of $312.08 on account
480915 - pending justification of coinsurance charges, per Bob's spreadsheet
480916 - received with his letter today, shown below. ref SDS 0 WN4F
480917 -
480918 -            [On 070919 responded to UCSF letter on 070912 received
480919 -            today, ref SDS 15 EZ5J, and request meeting with Kaiser to
480920 -            develop referral coordination plan with solid footing for
480921 -            continuing Millie's referral treatment. ref SDS 15 I55W
480923 -  ..
480924 - Bob's letter from UCSF continues...
480925 -
480926 -    2.  Your facility accounts have been reviewed by UCSF's Manager for
480927 -        Medicare billing.  He made a number of adjustments, resulting
480928 -        in your Patient responsibility being lowered. ref DRT 1 615O
480930 -         ..
480931 -    3.  I am attaching a revised spreadsheet that reflects your recent
480932 -        payments & adjustments UCSF has made to your accounts.  The
480933 -        amount you are responsible for is the coinsurance, which I have
480934 -        highlighted.  There are several accounts that we are still
480935 -        waiting for a response from Medicare. ref DRT 1 846G
480937 -  ..
480938 - The spreadsheet attached in Bob's letter, ref DRT 1 I49O, reduced by
480939 - approximately 80% ($8,000) the UCSF claim annualized for $10K received
480940 - from UCSF during the meeting on 070830, ref SDS 10 H54O, and is
480941 - rendered here in the record for convenient reference without dates of
480942 - payment by Medicare and the patient.
480944 -  ..
480945 - The amount of reduction appears to be primarily related to eliminating
480946 - improper charges for blood tests, discussed at UCSF on 070830.
480947 - ref SDS 10 T149
480948 -
480949 -            [...below notify Millie traveling on vacation. ref SDS 0
480950 -            SM5U
480952 -             ..
480953 -            [On 070919 notified Jackie to order blood tests at UCSF to
480954 -            start the next cycle of treatment for Millie on 070920.
480955 -            ref SDS 14 TZ9Q
480957 -             ..
480958 -            [On 070927 Kaiser EOC section 2 requires Kaiser to
480959 -            prescribe necessary treatment and pay for covered services,
480960 -            like oncology, ref SDS 17 WS6M, cutting the patient loose
480961 -            without Kaiser vast resources of billing expertise makes
480962 -            patients inviting targets for billing irretularities.
480963 -            ref SDS 17 WW4O
480965 -             ..
480966 -            [On 071015 charges for blood tests continue to appear on
480967 -            UCSF invoices for clinical trial referral work; Millie asks
480968 -            UCSF to order blood tests at Kaiser in order to evaluate if
480969 -            this change will resolve payment dispute. ref SDS 22 KH5T
480971 -  ..
480972 - Note the order in the UCSF spreadsheet is unclear.  For review
480973 - purposes an alternate order was produced showing accounts in
480974 - chronology by dates of service...
480975 -
480976 -              g: 08 02 04 60 07 09 1201b.xls
480978 -  ..
480979 - The UCSF spreadsheet shows...
480980 -
480981 -        UCSF Facility Billing
480983 -        Date:  September 12, 2007
480984 -
480985 -        <--------- UCSF Services ----------->  <- Medicare Payments ->  <------- Patient --------------->
480986 -        Account      Date    Type    Charges      Payment   Adjustment  Coinsurance   NC Svc     Payments
480987 -        12571560  20070130  OOV     $101.00     $111.54     -$38.42       $27.88                $27.88
480988 -        12575680  20070201  OTX   $2,997.00     $752.12   $1,314.86      $188.02    $722.00      $0.00
480989 -        12575738  20070201  OOV     $101.00      $89.02     -$10.28       $22.26                $22.26
480990 -        12575761  20070301  OOV     $101.00      $89.02     -$10.28       $22.26                $22.26
480991 -        12575768  20070308  OOV       $0.00                                                      $0.00
480992 -        12588856  20070208  OOV     $101.00     $111.54     -$38.42       $27.88                $27.88
480993 -         ..
480994 -        12593370  20070301  OTX   $4,549.49   $1,776.54   $1,531.99      $202.65  $1,028.31      $0.00
480995 -        12652072  20070222  OOV     $101.00      $89.02     -$10.28       $22.26                 $0.00
480996 -        12720616  20070315  OOV     $101.00     $111.54     -$38.42       $27.88                $27.88
480997 -        12762558  20070329  OOV     $101.00     $111.54     -$38.42       $27.88                $27.88
480998 -        12762597  20070426  OOV   $1,049.59     $569.74     $323.78       $22.26    $133.81     $22.26
480999 -        12762609  20070510  OOV     $101.00     $111.54     -$38.42       $27.88                $27.88
481000 -        12762615  20070524  OOV   $1,094.59     $658.03     $341.35       $27.88    $67.83      $27.88
481001 -        12762673  20070412  OOV       $0.00                                                      $0.00
481002 -        12763636  20070405  OTX   $2,114.32     $698.82     $983.38      $162.12    $270.00      $0.00
481003 -        12764302  20070503  OTX   $3,342.32   $1,186.24   $1,872.12      $283.96                 $0.00
481004 -        12880922  20070419  OOV     $315.07     $125.96     $161.23       $27.88                $27.88
481005 -        12997805  20070719  OOV     $101.00                                                      $0.00
481006 -        12997818  20070802  OOV     $101.00                                                      $0.00
481007 -        12997853  20070607  OOV     $101.00     $111.54     -$38.42       $27.88                $27.88
481008 -        12997859  20070621  OOV   $1,049.59     $143.72     $749.80       $22.26    $133.81     $22.26
481009 -        12997886  20070607  OTX   $3,489.59     $821.70   $1,625.77      $162.12    $880.00      $0.00
481010 -        12997900  20070705  OTX   $3,103.00   $1,212.82   $1,572.73      $173.39    $144.52      $0.00
481011 -        12997919  20070802  OTX   $4,338.09                                                      $0.00
481012 -        13171190  20070712  OOV       $0.00                                                      $0.00
481013 -        12363984  20070816  OOV      $81.00                                                      $0.00
481014 -        13284510  20070906  OTX     $565.00                                                      $0.00
481015 -        13284530  20071004  OTX       $0.00                                                      $0.00
481017 -         ..
481018 -        Totals                   $29,199.65   $8,881.99  $10,215.65    $1,506.60  $3,380.28    $312.08
481020 -         ..
481021 -        Patient payment on account pending
481022 -        justification from UCSF........................................ -$312.08
481024 -         ..
481025 -        UCSF claim for coinsurance currently due...................... $1,194.52
481026 -
481027 -            [On 071026 UCSF demands payment from Millie in 1 week for
481028 -            charges to provide medical care which are owed by Kaiser.
481029 -            ref SDS 24 SU5V
481030 -
481031 -            [On 071031 Millie receives notice dated 071026 UCSF has
481032 -            scheduled assignment to a collection agency for payment of
481033 -            account 12493370 in the amount of $202.65, ref SDS 26 KK4I,
481034 -            reviewed on 070830, ref SDS 10 4P8K, and revised again on
481035 -            070917, ref SDS 0 MK4H; there is no indication of UCSF
481036 -            collection efforts against Kaiser who ordered the work; and
481037 -            in a separate notice the next day on 071027 UCSF threatens
481038 -            that Millie's treatment for cancer ordered on referral by
481039 -            Kaiser will be terminated if UCSF does not receive payment
481040 -            from Millie, which is owed by Kaiser. ref SDS 26 KM8J
481042 -  ..
481043 - UCSF claim against Millie of $1,506.60 annualizes to about $2,000.
481044 - This is about $8,000 lower than the amount claimed leading up to the
481045 - meeting at UCSF on 070830 when Bob presented a spreadsheet showing a
481046 - claim for $4,254.12, ref SDS 10 H54O, which annualized at $10K per
481047 - year. ref SDS 10 W05N  This shows progress toward resolving billing
481048 - dispute requested in the letter to UCSF and Kaiser on 070909.
481049 - ref SDS 13 6P3V
481050 -
481051 -            [...below notify Millie traveling on vacation. ref SDS 0
481052 -            SM5U
481054 -             ..
481055 -            [On 071006 Millie received additional billings from UCSF
481056 -            that indicate total charges would be in the range of $15K -
481057 -            $20K per year. ref SDS 20 PRWW
481059 -             ..
481060 -            [On 071128 Kaiser Appeals Committee approved payment for
481061 -            Millie's care on referral to UCSF. ref SDS 28 JZ5R
481063 -  ..
481064 - What remains unclear in UCSF's claim is the actual APC rates being
481065 - charged and the items of cost applying the rates that accumulate to
481066 - the total charge UCSF seeks to recover in the revised spreadsheet, per
481067 - above. ref SDS 0 WP5I
481069 -  ..
481070 - For example, UCSF invoices show mostly charges for blood tests,
481071 - illustrated on 070830. ref SDS 10 4P8K  As well, there are a lot of
481072 - charges that seem like work paid by the clinical trial, per Doctor
481073 - Rugo's letter on 061230, and noted on 070830. ref SDS 10 WN9N
481074 -
481075 -        [On 070927 Kaiser guidance for Senior Advantage calls for no
481076 -        coinsurance charges on laboratory work to support clinical
481077 -        trials. ref SDS 17 4B4N
481079 -  ..
481080 - Millie's insurance with Kaiser requires copayment of $30 for doctor
481081 - visits, and $20 for blood tests.  She has no copayment for treatment
481082 - with chemotherapy in the Infusion Clinic at Kaiser.  She has had 2
481083 - doctor visits per month the past 8 months at UCSF, and she gets 1
481084 - blood test a month. 16 x 30 = $480 and 8 x 20 = $160.  Adding 480 +
481085 - 160 = $640.
481087 -  ..
481088 - UCSF needs to reconcile the $900 difference between its claim of $1500
481089 - against $640.
481091 -  ..
481092 - Entitlement of UCSF claim to recover coinsurance is reviewed below.
481093 - ref SDS 0 596Q
481095 -  ..
481096 - Regardless of entitlement and quantum, coinsurance presents issues of
481097 - accountability, cost, and health discussed with Bob Schwartz at UCSF
481098 - on 070830. ref SDS 10 T94O
481099 -
481100 -                [On 070927 16 legal issues arise from Kaiser's failure
481101 -                to perform duty to pay for prescribed treatment.
481102 -                ref SDS 17 WU6M
481104 -  ..
481105 - Following comments assist review for future referrals...
481106 -
481107 -        1.  To recover copayments or coinsurance of $1,500 over an 8
481108 -            month period of services has required expenditure of
481109 -            approximately...
481110 -
481111 -            a.  100 pieces of paper, including 60 or so envelopes, with
481112 -                attendant costs of distribution through the US Mail
481113 -                system and mostly delivered within a 2 month period,
481114 -                reported on 070823, ref SDS 8 X16N, and discussed with
481115 -                Bob Schwartz at UCSF accounting on 070830. ref SDS 10
481116 -                H54O
481118 -                 ..
481119 -            b.  For a patient being treated at Kaiser for 30 years, who
481120 -                never sees much detail on invoicing, this rush of
481121 -                documentation presents a significant emotional shock.
481122 -                The cost to the patient in time and effort, or to hire
481123 -                someone to read, and assess what to pay, illustrated by
481124 -                the record on 070823, ref SDS 8 RV6U, and the meeting
481125 -                with UCSF on 070830, ref SDS 10 4P8K, is overwhelming,
481126 -                shown by the record today. ref SDS 0 596Q  Fear about
481127 -                paying anything without knowledge of total outlay is
481128 -                only matched by fear of losing treatment in the absence
481129 -                of payment.  Without initial understanding about the
481130 -                approximate costs of treatment, a patient has no
481131 -                rational way to determine if payment of $1,500, $4,500
481132 -                or $6,000 demanded in one statement will be duplicated
481133 -                in a week, a month, or a year.
481135 -                 ..
481136 -                Medicare seems to call on the clinical trial service
481137 -                provider to notify the customer about amounts owed, and
481138 -                to manage the billing process.  Yet, UCSF maintains
481139 -                they cannot do this, because Kaiser's Medicare unit
481140 -                withholds charges until after-the-fact analysis,
481141 -                eliminating proactive exercise of patient due diligence
481142 -                for cost containment, reported on 070830. ref SDS 10
481143 -                WU5N
481144 -
481145 -                   [On 070906 UCSF Clinical Trial Director confirms
481146 -                   Kaiser made the referral and the patient was not
481147 -                   notified of extra charges for coinsurance, because
481148 -                   nobody knew anything about this issue when treatment
481149 -                   was started on 070201. ref SDS 12 I49K
481151 -             ..
481152 -        2.  There is no evident correlation between any amount claimed
481153 -            by UCSF and any amounts in detailed invoices of 100 or so
481154 -            pages containing thousands of detailed charges, illustrated
481155 -            by example using invoice #12593370 presented by Bob
481156 -            Schwartz during the meeting at UCSF on 070830. ref SDS 10
481157 -            4P8K  Another example is the first entry in the spreadsheet
481158 -            received today with UCSF's letter dated 070912, per above,
481159 -            ref SDS 0 HP4K, and shows...
481161 -         ..
481162 -        12571560  2007 01 30  OOV     $101.00     $111.54     -$38.42       $27.88                $27.88
481163 -
481164 -            During the meeting on 070830 UCSF explained that amounts in
481165 -            the spreadsheet received at that time and for $101 were for
481166 -            "doctor visits."  He checked all these lines with an ink
481167 -            pen to facilitate calculating an interim payment of
481168 -            coinsurance. ref SDS 10 VT5W  The invoice for this line
481169 -            item shows the following...
481171 -         ..
481172 -        013007 1 1260826 OUTPATIENT EST LEV 5 INST ZBP      101.00
481173 -        013007 1 0600010 TECH FEE ADJUSTMENT - Z8           101.00-
481174 -        013007 1 0600010 TECH FEE ADJUSTMENT - Z8           101.00
481175 -        031407 1 0010610 M-CARE OP PAYMENT                    0.00
481176 -        071007 1 0100005 ACCOUNT BALANCE TRANSFER           101.00
481177 -        071007 1 0100005 ACCOUNT BALANCE TRANSFER           101.00-
481178 -        072407 1 0101005 DENIED - CO-INSURANCE               27.88
481179 -        072407 1 0010610 M-CARE OP PAYMENT                  111.54
481180 -        072407 1 0101005 DENIED - CO-INSURANCE               27.88-
481181 -        072407 1 0300610 M-CARE OP PAYMENT ADJ               38.42
481183 -         ..
481184 -        SUMMARY OF CURRENT PAYMENTS ADJUSTMENTS              73.12-
481185 -        SUMMARY OF CURRENT CHARGES CLINIC                   101.00
481186 -        TOTAL OF CURRENT CHARGES                            101.00
481188 -         ..
481189 -        TOTALS                                               27.88
481190 -        PAY THIS AMOUNT                                      27.88
481192 -             ..
481193 -            As well, the next claim for coinsurance on visiting the
481194 -            doctor is for....
481196 -         ..
481197 -        12575738  2007 02 01  OOV     $101.00      $89.02     -$10.28       $22.26                $22.26
481199 -             ..
481200 -            The detailed invoice shows...
481202 -         ..
481203 -        020107 1 1260826 OUTPATIENT EST LEV 4 INST ZBP      101.00
481204 -        020107 1 0600010 TECH FEE ADJUSTMENT - Z8           101.00-
481205 -        020107 1 0600010 TECH FEE ADJUSTMENT - Z8           101.00
481206 -        031407 1 0010610 M-CARE OP PAYMENT                    0.00
481207 -        072407 1 0101005 DENIED - CO-INSURANCE               22.26
481208 -        072407 1 0010610 M-CARE OP PAYMENT                   89.02
481209 -        072407 1 0101005 DENIED - CO-INSURANCE               22.26-
481210 -        072407 1 0300610 M-CARE OP PAYMENT ADJ               10.28
481212 -         ..
481213 -        SUMMARY OF CURRENT PAYMENTS ADJUSTMENTS              78.74-
481214 -        SUMMARY OF CURRENT CHARGES CLINIC                   101.00
481215 -        TOTAL OF CURRENT CHARGES                            101.00
481217 -         ..
481218 -        TOTALS                                               22.26
481219 -        PAY THIS AMOUNT                                       0.00
481220 -
481221 -            Since the invoice says to pay 0.00, why does the
481222 -            spreadsheet say to pay $22.26?
481223 -
481224 -            Obviously, UCSF has developed a very sophisticated and
481225 -            perhaps efficient billing system for experienced
481226 -            accountants, and medical cost specialists.  This does not
481227 -            meet requirements for billing customers who do not have
481228 -            familiarity with UCSF accounting algorithms and
481229 -            descriptions of compensable services.  On 070823 Bob
481230 -            Schwartz seemed to indicate that UCSF does not actually
481231 -            determine amounts to bill customers; rather they merely
481232 -            relay manipulations furnished by people at Medicare
481233 -            contractor (FI - Fiscal Intermediary), in this case Kaiser.
481234 -            ref SDS 8 RW3R
481236 -             ..
481237 -        3.  UCSF detailed invoices appear to show a lot of charges that
481238 -            are paid by the clinical trial, e.g., for chemotherapy
481239 -            drugs, blood draws, etc., as previously reviewed on 070823.
481240 -            ref SDS 8 Y53J  This seems conflicting with agreement
481241 -            between Kaiser and UCSF on 061230 that Millie would not be
481242 -            charged for costs of the clinical trial, and that Kaiser
481243 -            would pay for all other costs for routine care (standard of
481244 -            care). ref SDS 3 3X6K  There is appearance that UCSF is
481245 -            billing Medicare for costs paid by others.  UCSF has not
481246 -            shown their calculation of charges aligns with legal
481247 -            limitations.
481248 -
481249 -
481250 -
4813 -

SUBJECTS
Default Null Subject Account for Blank Record

4903 -
490401 -  ..
490402 - Prescribed Treatment Services Does Not Apply to Coinsurance
490403 - Coinsurance Justification CMS Regulatory and Statutory Review
490404 - Coinsurance Does Not Apply to Any Services for Prescribed Treatment
490405 - CMS 69.9 Coinsurance Clinical Trials Not Apply to Prescribed Treatment
490406 -
490407 -
490408 - Bob's letter from UCSF to Millie continues...
490410 -         ..
490411 -    4.  I have also attached part of the Medicare Manual that states
490412 -        Managed care enrollees are liable for the co-insurance amounts
490413 -        applicable to services paid under Medicare fee for service
490414 -        rules.  I have paperclipped & highlighted subsection 69.9 of
490415 -        the manual that explains this. ref DRT 1 H46M
490417 -         ..
490418 -    5.  You & Mr Welch are welcome to contact me regarding any UCSF
490419 -        Medical Center facility billing. ref DRT 1 H47I
490420 -
490421 -              [On 070924 letter from Bob on 070920 confirms UCSF
490422 -              support for questions on billings. ref SDS 16 N45S
490423 -
490424 -              [On 071009 UCSF called and asked Kaiser to call and tell
490425 -              Millie that UCSF complains and objects to being notified
490426 -              of efforts to assist Kaiser paying UCSF billings for
490427 -              treating Millie on referral from Kaiser. ref SDS 21 X65I
490429 -         ..
490430 -    6.  I hope you had a pleasant time on your vacation. ref DRT 1 P47M
490432 -  ..
490433 - CMS section 69.9 on page 8 states in part...
490434 -
490435 -            Managed care enrollees are liable for the coinsurance
490436 -            amounts applicable to services paid under Medicare fee for
490437 -            service rules. ref OF 2 TX67
490439 -  ..
490440 - This responds to Millie's request for justification of coinsurance
490441 - charges in the UCSF claim discussed during the meeting on 070830,
490442 - ref SDS 10 W06L, and accomplishes the UCSF action item planned at that
490443 - time. ref SDS 10 T25H  Millie's letter on 070904 confirmed request for
490444 - justification of coinsurance charges, ref SDS 11 6R4W, and this was
490445 - cited in a follow up letter to UCSF on 070909. ref SDS 13 6O6T
490447 -  ..
490448 - UCSF reliance on CMS section 69.9, ref SDS 0 596Q, does not support
490449 - entitlement in this case to payment from the patient for coinsurance
490450 - at the rate of 56% on indeterminable amounts, shown in UCSF's claim
490451 - received during the meeting on 070830. ref SDS 10 X16N  Coinsurance
490452 - does not apply to any services in this transaction, because Kaiser
490453 - agreed on 061230 to pay any costs not covered by the clincial trial
490454 - that are reasonable and necessary services for prescribed treatment.
490455 - ref SDS 3 3X6K  On 070105 Millie's doctor prescribed treatment at
490456 - UCSF, and did not disclose charges of coinsurance, since Kaiser had
490457 - already agreed on 061230 to pay for the work. ref SDS 4 PK68
490459 -  ..
490460 - Millie did not agree to get treatment at UCSF that increased cost of
490461 - care for coinsurance under Medicare fee for service rules governing
490462 - clinical trials.  Application of fee for service procedures was never
490463 - presented.  Payment for the work is solely a matter between Kaiser and
490464 - UCSF.  Millie went to UCSF because her doctor prescribed treatment in
490465 - the same way Millie went to Mt Diablo hospital to get radiation
490466 - treatment prescribed by the doctor in 2002, and further in the same
490467 - way that Millie went to the Infusion Clinic at Kaiser in Walnut Creek
490468 - for treatment in a clinical trial prescribed by the doctor in 2004, as
490469 - related previously during the meeting at UCSF on 070830. ref SDS 10
490470 - LQ5I
490472 -             ..
490473 -            [On 070927 Kaiser Senior Advantage EOC Section 2 requires
490474 -            the doctor to prescribe needed care for covered Services,
490475 -            in this case oncology. ref SDS 17 WS6M
490477 -             ..
490478 -            [On 070927 Kaiser Senior Advantage EOC Section 7 explains
490479 -            patients can volunteer for treatment in a clinical trial
490480 -            and will be charged 20% for coinsurance, and that patients
490481 -            should ask the clinical trial provider for an estimate of
490482 -            costs. ref SDS 17 1F67
490484 -  ..
490485 - During the meeting on 070830 UCSF claimed entitlement 8 months after
490486 - starting the work in January against Millie on grounds advanced by
490487 - Kaiser in refusing payment of bills which UCSF sent to Kaiser, and
490488 - claiming that patients who self-refer for treatment in a clinical
490489 - trial must be treated and UCSF should bill primary insurance to
490490 - Medicare, and bill the patient for coinsurance. ref SDS 10 NQ3F
490492 -  ..
490493 - Kaiser's analysis is incorrect, because in this case Millie did not
490494 - "self-refer" to participate in a clinical trial helping researchers
490495 - advance science. ref SDS 10 EH9K  On 070105 Kaiser prescribed
490496 - treatment on referral to UCSF as necessary for performing Kaiser's
490497 - duty to provide standard of care for oncology practice, ref SDS 4
490498 - PK7L, cited previously in Kaiser's letter on 060809 explaining pattern
490499 - and practice that earn Kaiser a reputation for "good care."
490500 - ref SDS 2 NT9X  Kaiser's pattern and practice to prescribe clinical
490501 - trials to perform duties of routine care was presented beginning on
490502 - 040318, ref SDS 1 DG4J, as shown in the case study listed on 070830.
490503 - ref SDS 10 LQ5I
490505 -             ..
490506 -            [On 070927 Millie found documentation from Kaiser describes
490507 -            coinsurance for "self-referral" to participate in clinical
490508 -            trials for medical research, ref SDS 17 1G4O, which does
490509 -            not apply to services EOC section 2 for Millie's treatment
490510 -            at UCSF prescribed by Kaiser for routine care. ref SDS 17
490511 -            1F92
490513 -  ..
490514 - UCSF reliance on Medicare CMS support for "self-referral" does not
490515 - apply in this case, because Kaiser made the referral and agreed in a
490516 - letter to UCSF on 061230 that Kaiser would pay any costs not paid by
490517 - the clinical trial, ref SDS 3 PO3Q, as further discussed during the
490518 - meeting at UCSF on 070830. ref SDS 10 T24Q  The letter from the UCSF
490519 - clinical trial director received on 070906 confirms that Kaiser made
490520 - the referral. ref SDS 12 UK5M
490522 -  ..
490523 - Bob indicated during the meeting at UCSF on 070830 that if Millie were
490524 - treated at Kaiser, she would not incur charges claimed by UCSF.
490525 - Review at that time showed Millie was only liable for nominal
490526 - co-payment charges for treatment in a clinical trial at Kaiser during
490527 - 2004. ref SDS 10 NQ3F
490529 -  ..
490530 - Further at the meeting on 070830, Bob identified UCSF coinsurance
490531 - claims only for $110 charges to visit with the doctor, and this
490532 - results in variable charges of $22.26 and $27.88, per his spreadsheet
490533 - today, shown above. ref SDS 0 WP5I
490535 -  ..
490536 - Bob recommended that patients review Medicare regulations to verify
490537 - obligations to pay coinsurance for participating in clinical trials.
490538 - His letter received today cites CMS section 69.9. ref SDS 0 596Q
490539 -
490541 -  ..
490542 - Coinsurance Copayments Same Meaning CMS Regulations
490543 -
490544 - Research CMS 69.9 shown below, ref SDS 0 IO9R, yielded additional
490545 - authority showing that coinsurance and copayment are used by Medicare
490546 - interchangeably to mean the same thing.  It also, appears that Kaiser
490547 - may be responsible to pay for coinsurance. ref SDS 0 TO4F
490549 -  ..
490550 - For example...
490552 -  ..
490553 - Coinsurance 20% Minimum Encourages Participation Private Insurance
490554 - Title 42 part 419.40 says in part...
490555 -
490556 -            c.) For purposes of this section...
490557 -
490558 -            (1. Coinsurance percentage is calculated as the difference
490559 -            between the program payment percentage and 100 percent.
490560 -            The coinsurance percentage in any year is thus defined for
490561 -            each APC group as the greater of the following: the ratio
490562 -            of the APC group unadjusted copayment amount to the annual
490563 -            APC group payment rate, or 20 percent.
490565 -               ..
490566 -              http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/cfr_2002/octqtr/pdf/42cfr419.41.pdf
490568 -  ..
490569 - This indicates the minimum coinsurance is 20%.
490571 -  ..
490572 - Title 42 sources are listed below. ref SDS 0 YR4G
490574 -  ..
490575 - What is the basis of UCSF billing 56% shown in the UCSF spreadsheet
490576 - received on 070830? ref SDS 10 WP5I
490577 -
490579 -  ..
490580 - Review Title 42 part 419.40 continues...
490581 -
490582 -            (c) Limitation of copayment amount to inpatient hospital
490583 -            deductible amount.  The copayment amount for a procedure
490584 -            performed in a year cannot exceed the amount of the
490585 -            inpatient hospital deductible established under section
490586 -            1813(b) of the Act for that year. [66 FR 59922, Nov. 30,
490587 -            2001]
490588 -
490589 -                [...see below for more. ref SDS 0 KR4K
490591 -  ..
490592 - This section suggests that UCSF should submit the amount of the
490593 - hospital deductible for each procedure charged to Millie's account, in
490594 - order to establish the maximimum annual coinsurance entitlement UCSF
490595 - can claim against Millie.
490597 -  ..
490598 - This section does not expressly state that coinsurance is limited to
490599 - Part A activity evidently associated with hospitalization.  If
490600 - limitations apply also to Part B then there may be a cap on Millie's
490601 - exposure to coinsurance obligations that cannot exceed deductibles for
490602 - inpatient hospital care.
490603 -
490604 -                [...below CMS guidance seems to confirm coinsurance for
490605 -                outpatient care is limited to annual deductible for
490606 -                inpatient care. ref SDS 0 QT3K
490608 -  ..
490609 - Section  419.41 Calculation of national beneficiary copayment amounts
490610 - and national Medicare program payment amounts... describes a very
490611 - complex procedure for determining annual coinsurance rates.  Since
490612 - these amounts are fixed for a year, they are subject to disclosure to
490613 - beneficiaries for purposes of deciding hire a service provider based
490614 - on comparative value in the market place.
490615 -
490616 -                [...below, CMS publishes procedure to calculate
490617 -                coinsurance for APC group rates. ref SDS 0 WV5I
490619 -  ..
490620 - Review Title 42 part 419.40 continues...
490621 -
490622 -             419.42 Hospital election to reduce coinsurance
490623 -
490624 -            d.) A hospital may elect to reduce coinsurance for any or
490625 -            all APC groups on a calendar year basis.  A hospital may
490626 -            not elect to reduce copayment amounts for some, but not
490627 -            all, services within the same group.
490629 -             ..
490630 -            (b) A hospital must notify its fiscal intermediary of its
490631 -            election to reduce coinsurance no later than-
490632 -
490633 -            (1. June 1, 2000, for coinsurance elections the period July
490634 -            1, 2000 through mber 31, 2000; or
490635 -
490636 -            (2) December 1 preceding the beginning of each subsequent
490637 -            calendar year.
490639 -             ..
490640 -            (c) The hospital's election must be properly documented.
490641 -            It must specifically identify the APCs to which it applies
490642 -            and the copayment amount (within the limits identified
490643 -            below) that the hospital has selected for each group.
490645 -             ..
490646 -            (d) The election of reduced coinsurance remains in effect
490647 -            unchanged during the year for which the election was made.
490649 -             ..
490650 -            (e) In electing reduced coinsurance, a hospital may elect a
490651 -            copayment amount that is less than that year's
490652 -            wage-adjusted copayment amount for the group but not less
490653 -            than 20 percent of the APC payment rate as determined in 
490654 -            419.32.
490656 -  ..
490657 - Under  419.42 UCSF should disclose the amount it has elected to
490658 - reduce coinsurance for each APC payment rate being billed to Millie's
490659 - account so that Millie can shop for comparative value.
490661 -  ..
490662 - Review Title 42 part 419.40 continues...
490663 -
490664 -            (f) The hospital may advertise and otherwise disseminate
490665 -            information concerning the reduced level of coinsurance
490666 -            that it has elected.  All advertisements and information
490667 -            furnished to Medicare beneficiaries must specify that the
490668 -            coinsurance reductions advertised apply only to the
490669 -            specified services of that hospital and that coinsurance
490670 -            reductions are available only for hospitals that choose to
490671 -            reduce coinsurance for hospital outpatient services and are
490672 -            not allowed in any other ambulatory settings or physician
490673 -            offices.
490675 -             ..
490676 -            [65 FR 18542, Apr. 7, 2000, as amended at 65 FR 67829, Nov.
490677 -            13, 2000; 66 FR 59923, Nov. 30, 2001]
490679 -  ..
490680 - Stuatory notice for service providers to advertise reduced
490681 - coinsurance, ref SDS 0 6G5H, encourages market competition that gives
490682 - Medicare beneficiaries choices for buying supplemental medical
490683 - insurance that contains costs.
490685 -  ..
490686 - Additonally, Medicare policy requires secondary, supplemental
490687 - insurance carriers to pay for coinsurance billings that exceed 20% of
490688 - rising medical costs, ref SDS 0 IP8L, so that patients do not
490689 - encounter difficulties reported in this case, reviewed above.
490690 - ref SDS 0 WO60
490692 -  ..
490693 - When Kaiser elected to have Millie "self-refer" as a Medicare
490694 - beneficiary to get treatment at UCSF in the cetuximab carboplatin
490695 - clinical trial, and withheld the doctor's signed authoriztion for
490696 - Kaiser to make the referral, this placed Kaiser in the role of
490697 - Millie's secondary insurance carrier with respect to this transaction.
490698 - CMS reports that secondary insurance carriers are responsible for
490699 - paying coinsurance amounts denied by primary Medicare. ref SDS 0 GX6I
490701 -  ..
490702 - Kaiser Senior Advantage which is currently Millie's health care
490703 - provider says the same thing, that this secondary coverage pays for
490704 - coinsurance obligations under Medicare. ref SDS 0 IP8L  Kaiser's
490705 - responsibilities for Medigap coverage is further shown by Kaiser's
490706 - publications, telling patients to cancel Medigap insurance after
490707 - Senior Advantage become effective, per below. ref SDS 0 EZ56
490709 -  ..
490710 - Medicare regulations expressly state that Medigap coverage must pay
490711 - coinsurance obligations for patients in clinical trials. ref SDS 0
490712 - WQ3G
490714 -  ..
490715 - Accordingly, there is no basis for UCSF to bill Millie for
490716 - coinsurance.  This supports understandings between Kaiser and UCSF on
490717 - 061230 that Kaiser would pay for all costs of Millie's treatment not
490718 - paid by the clinical trial. ref SDS 3 3X6K
490719 -
490720 -
490722 -  ..
490723 - UCSF Invites Customer Questions Clarifying Billings
490724 -
490725 -
490726 - Bob's letter from UCSF concludes...
490727 -
490728 -    7.  You & Mr.  Welch are welcome to contact me regarding any UCSF
490729 -        Medical Center facility billing. ref DRT 1 H47I
490731 -         ..
490732 -    8.  I hope you had a pleasant time on your vacation. ref DRT 1 P47M
490733 -
490734 -
490736 -  ..
490737 - CMS Centers for Medicare and Medicaide Systems Procedures
490738 -
490739 - Further review shows there is an Interent address for CMS...
490740 -
490741 -        CMS Programs and Information
490742 -
490743 -              http://www.cms.hhs.gov/
490744 -
490745 -
490746 -
4908 -

SUBJECTS
CMS Announcement Clinical Trials Investigational Device Exemption NH

8903 -
890401 -         ..
890402 -        Investigational Devices and Clinical Trials
890403 -        Clinical Trial Medicare Policy Exemptions and Exceptions
890404 -
890405 -        CMS publishes guidance that seems to correlate policy and
890406 -        practices using clinical trials as part of "investigational
890407 -        devides."  This was located with Search criteria...
890408 -
890409 -                Medicare "Title 42" "clinical trial"
890411 -         ..
890412 -        NHIC, Corp
890413 -        CMS contractor
890415 -               ..
890416 -              http://www.medicarenhic.com/
890418 -         ..
890419 -        Medicare Part B Contractor, ISO 9001 Certified
890420 -        Durable Medical Equipment Medicare Administrative Contractor
890422 -         ..
890423 -        NHIC, Corp., an ISO 9001:2000 Certified Quality Management
890424 -        System is the Medicare Part B contractor for California,
890425 -        Maine, Massachusetts, New Hampshire, and Vermont, serving 4.0
890426 -        million beneficiaries and 142,000 healthcare providers.
890428 -         ..
890429 -        Investigational Device Exemption
890431 -         ..
890432 -        NHIC CMS paper dated 070419 REF-EDO-0027, ref OF 3 0001
890433 -
890434 -              http://www.medicarenhic.com/providers/billing/ideguide_apr2007.pdf
890436 -         ..
890437 -        Medicare covers certain medical devices (and services related
890438 -        to those devices) that are being studied as part of a Food and
890439 -        Drug Administration (FDA) approved clinical trial, but have not
890440 -        been approved for marketing.  The requirements of coverage for
890441 -        the Investigational Device Exemption (IDE) and the CMS
890442 -        regulatory requirements are available in Title 42 Code of
890443 -        Federal Regulations. ref OF 3 0001
890445 -         ..
890446 -        Background
890448 -         ..
890449 -        The Social Security Act (the Act) provides Medicare coverage
890450 -        for broad categories of benefits through both Part A and Part B
890451 -        of Medicare.  The Act does not, however, provide an
890452 -        all-inclusive list of covered items, services, treatments,
890453 -        procedures or technologies. ref OF 3 PE45
890455 -         ..
890456 -        Congress vested the Secretary with the responsibility to make
890457 -        coverage determinations when the Act is silent.  These
890458 -        determinations are to be made using Section 1862(a)(1)(A) of
890459 -        the Act, which requires:
890460 -
890461 -        a.  the service to be reasonable and necessary for the
890462 -            diagnosis and treatment of illness, ref OF 3 PE54, and
890464 -             ..
890465 -        b.  that the service must not be excluded elsewhere in the Act.
890466 -            ref OF 3 HQ7L
890468 -         ..
890469 -        Historically, CMS has interpreted the statutory terms
890470 -        "reasonable" and "necessary" to mean that a device must be safe
890471 -        and effective, medically necessary, and not experimental.  For
890472 -        most Medicare coverage purposes, the term experimental has been
890473 -        used synonymously with the term investigational. ref OF 3 YF6I
890475 -  ..
890476 - This analysis suggests clinical trial work in Millie's case to
890477 - investigate effectiveness of cetuximab with carboplatin for breast
890478 - cancer, is per se "investigational," and therefore "experimental,"
890479 - which would result in finding treatment is not reasonable and
890480 - necessary.  This conflicts with the doctor's determination on 070105
890481 - that the treatment is reasonable and necessary. ref SDS 4 PK68
890483 -  ..
890484 - Experience over the past 10 months has proven the doctor's
890485 - determination on 070105 was correct, reported 070904. ref SDS 11 KM3K
890487 -  ..
890488 - CMS using "experimental" synomously with investigational for clinical
890489 - trial treatment may be too narrow for oncology care which relies on
890490 - clinical trials to expand the doctor's "tool kit," explained on 040318
890491 - at Kaiser. ref SDS 1 DG4J
890493 -  ..
890494 - This CMS guidance appears to specify billing procedures when patients
890495 - self-refer for treatment in clinical trials, rather than when doctors
890496 - prescribe treatment in a clinical trial.  Kaiser has revenue from
890497 - patient insurance premiums, and from Medicare also paid by patient
890498 - insurance premiums.  Kaiser is required to exercise good medical
890499 - practice spending revenue for patient care under section 2 of the
890500 - Senior Advantage EOC.
890501 -
890502 -            [On 070927 EOC section 2 Kaiser Senior Advantage requires
890503 -            the doctor to prescribe treatment needed for covered
890504 -            services. ref SDS 17 WS6M
890505 -
890507 -         ..
890508 -        Coinsurance Limited to Annual Inpatient Deductible
890509 -
890510 -
890511 -        Hospital Outpatient Prospective Payment System (PPS) Overview
890512 -        last updated 070815...
890513 -
890514 -              http://www.cms.hhs.gov/HospitalOutpatientPPS/01_overview.asp#TopOfPage
890515 -
890516 -        ...says in part...
890518 -         ..
890519 -        Section 4523 of the BBA [Balanced Budget Act 1997] also changed
890520 -        the way beneficiary coinsurance is determined for the services
890521 -        included under the PPS.  A coinsurance amount will initially be
890522 -        calculated for each APC based on 20 percent of the national
890523 -        median charge for services in the APC.  The coinsurance amount
890524 -        for an APC will not change until such time as the amount
890525 -        becomes 20 percent of the total APC payment.  In addition,
890526 -        Section 204 of the BBRA provides that no coinsurance amount can
890527 -        be greater than the hospital inpatient deductible in a given
890528 -        year.
890530 -  ..
890531 - This appears to implement code Title 42 section 419.40 (c) that limits
890532 - coinsurance payments, per above. ref SDS 0 TN4N
890534 -               ..
890535 -              http://www.cms.hhs.gov/ClinicalTrialPolicies/
890536 -
890537 - ...where policies and procedures can be reviewed in relation to
890538 - Medicare statutes and regulations.
890540 -  ..
890541 - Research on related Medicare publications found...
890542 -
890543 -        Department of Health & Human Services (DHHS)
890544 -
890545 -        Centers for Medicare & Medicaid Services (CMS)
890546 -        7500 Security Boulevard
890547 -        Baltimore, Maryland  21244
890549 -         ..
890550 -        CMS Manual System
890551 -        Pub 100-04 Medicare Claims Processing
890552 -        Transmittal 771
890554 -         ..
890555 -        Date: DECEMBER 2, 2005
890556 -        Change Request 4181
890558 -         ..
890559 -        SUBJECT:  Revisions to Pub. 100-04, Medicare Claims Processing
890560 -                  Manual in Preparation for the National Provider
890561 -                  Identifier (NPI)
890562 -
890563 -              http://www.cms.hhs.gov/Transmittals/Downloads/R771CP.pdf
890565 -         ..
890566 -        30.1 - Coinsurance Election
890567 -        (Rev.771, Issued: 12-02-05, Effective: 01-03-06,
890568 -        Implementation: 01-03-06)
890570 -         ..
890571 -        The transition to the standard Medicare coinsurance rate (20
890572 -        percent of the APC payment rate) will be gradual.  For those
890573 -        APC groups for which coinsurance is currently a relatively high
890574 -        proportion of the total payment, the process will be
890575 -        correspondingly lengthy.  The law offers hospitals the option
890576 -        of electing to reduce coinsurance amounts and advertise their
890577 -        reduced rates for all OPPS services.  They may elect to receive
890578 -        a coinsurance payment from Medicare beneficiaries that is less
890579 -        than the wage adjusted coinsurance amount per APC.  That amount
890580 -        will apply to all services within that APC.  This coinsurance
890581 -        reduction must be offered to all Medicare beneficiaries.
890583 -         ..
890584 -        The lesser amount elected:
890586 -                ..
890587 -            •  May not be less than 20 percent of the wage adjusted APC
890588 -               payment amount;
890590 -                ..
890591 -            •  May not be greater than the inpatient hospital
890592 -               deductible for that calendar year ($812 for 2002); and
890594 -                ..
890595 -            •  Will not be wage adjusted by the FI or CMS.
890596 -
890597 -
890598 -
890599 -
8906 -

SUBJECTS
CMS Coinsurance Clinical Trials Governance Application Medicare Bene

9903 -
990401 -  ..
990402 - CMS Governance Called for Application Coinsurance Clinical Trials
990403 -
990404 - This research yielded the name of...
990405 -
990406 -            Catherine Windfield-Jones, (410) 786-6674 for policy issues
990407 -            or Elizabeth Hale at (410) 786-7604 for actuarial issues.
990408 -
990409 - ...located at the bottom of...
990410 -
990411 -        August 2007
990412 -        ANNOUNCEMENT
990414 -         ..
990415 -        Out-of-Pocket Limits for Medigap Plans K & L for Calendar Year
990416 -        2008
990418 -               ..
990419 -              http://www.cms.hhs.gov/Medigap/Downloads/KLOOPLimits2008.pdf
990421 -  ..
990422 - Millie's coinsurance issue seems unrelated to Medigap "Plan A" that
990423 - pays for coinsurance, per below. ref SDS 0 GX6I  Clinical trials seem
990424 - to require secondary insurance to pay for coinsurance. ref SDS 0 LN9W
990425 - However, Kaiser prescribed Millie's care
990426 -
990427 -         [On 070927 Millie found documents indicating Kaiser's Senior
990428 -         Advantage insurance coverage excludes Medigap scope.
990429 -         ref SDS 17 1E91
990431 -  ..
990432 - Called and left a message for Cathy for guidance on Millie's coverage
990433 - through Senior Advantge, per below. ref SDS 0 WQ3G
990434 -
990435 -         [On 070927 Cathy returned the call, ref SDS 17 KA5J
990437 -          ..
990438 -         [On 070927 Kaiser's failure to perform legal duty to pay
990439 -         for needed oncology services covered by Senior Advantage
990440 -         EOC presents 16 policy issues for determination by Kaiser,
990441 -         CMS, Medicare, and perhaps the court. ref SDS 17 WU6M
990443 -          ..
990444 -         [On 071002 Mark followed up Cathy's call, and referred the
990445 -         matter to Jullin. ref SDS 18 LD5L
990447 -          ..
990448 -         [On 071003 James at CMS requested email to review Millie's
990449 -         case for clarifying CMS guidance. ref SDS 19 KA5J
990450 -
990451 -
990452 -
990453 -
990454 -
990455 -
990456 -
990457 -
990458 -
9905 -

SUBJECTS
American College of Radiology (ACR) Acronyms Medicare Calculating Pa

A903 -
A90401 -  ..
A90402 - Payments Procedures APC Groups Medicare and Acronyms
A90403 - APC Groups Medicare Calculating Payments Procedures and Acronyms
A90404 - Medicare Payments APC Groups Calculating Procedures and Acronyms
A90405 -
A90406 - American College of Radiology (ACR) publishes guidance on Medicare
A90407 - acronyms. ref OF 4 FI5I
A90409 -  ..
A90410 - This sources defines codes used for CMS billings by service
A90411 - providers.
A90412 -
A90413 -              http://www.acr.org/Hidden/Economics/FeaturedCategories/mps/hopps/2006HOP
A90414 -
A90415 -    1.  APC payment rates are calculated on a national basis and
A90416 -        adjusted by geographic area, depending on the area's wage
A90417 -        level. ref OF 4 FI5J
A90419 -         ..
A90420 -    2.  The Centers for Medicare and Medicaid Services (CMS) uses the
A90421 -        Inpatient Prospective Payment System (IPPS) wage index as the
A90422 -        source of a geographic adjustment factor for Hospital
A90423 -        Outpatient Prospective Payment System (HOPPS) ambulatory
A90424 -        payment classification (APC) payments. ref OF 4 FI54
A90426 -         ..
A90427 -    3.  In order to calculate the wage adjusted APC payment you must
A90428 -        know the following:, ref OF 4 8V6O
A90429 -
A90430 -             1.  The CPT code(s) for the procedure(s) you are
A90431 -                 determining payment for.
A90432 -             2.  The APC payment for the CPT code(s).
A90433 -             3.  The Core Based Statistical Area (CBSA).
A90434 -             4.  The IPPS wage index for the CBSA.
A90436 -         ..
A90437 -    4.  Definitions:
A90438 -
A90439 -             1.  Core Based Statistical Area (CBSA) - The term "core
A90440 -                 based statistical area" (CBSA) became effective in
A90441 -                 2000 and refers collectively to metropolitan and
A90442 -                 micropolitan statistical areas. ref OF 4 IK7J
A90444 -                  ..
A90445 -                 For more information go to [US Census Bureau]...
A90446 -
A90447 -                        http://www.census.gov/population/www/estimates/aboutmetro.html
A90449 -                  ..
A90450 -             2.  CPT - Current Procedural Terminology
A90452 -                  ..
A90453 -             3.  APC - Ambulatory Payment Classification.  All services
A90454 -                 paid under HOPPS are classified into APC groups.
A90455 -                 ref OF 4 4L8L
A90457 -                  ..
A90458 -                 Outpatient PPS payment is based on the ambulatory
A90459 -                 payment classification (APC) system, which divides all
A90460 -                 outpatient services included in the new payment
A90461 -                 schedule into almost 600 procedural groups.  The
A90462 -                 services within each group are clinically similar and
A90463 -                 require comparable resources.  Each APC is assigned a
A90464 -                 relative payment weight based on the median cost of
A90465 -                 the services within the APC.  The APC payment rates
A90466 -                 are calculated on a national basis and then adjusted
A90467 -                 by geographic area, depending on the area's wage
A90468 -                 level.  To adjust for wage differences across
A90469 -                 geographic areas, the labor-related portion of the
A90470 -                 payment rate (60 percent) is wage adjusted, using each
A90471 -                 hospital's wage index value. ref OF 4 K685
A90473 -         ..
A90474 -    5.  Performing the wage adjusted APC payment calculation:,
A90475 -        ref OF 4 IK9K
A90476 -
A90477 -             1.  Determine what CPT code(s) and CBSA(s) you are
A90478 -                 calculating the wage adjusted APC payment amount for.
A90480 -                  ..
A90481 -             2.  To locate the wage index by CBSA go to Table 4c on the
A90482 -                 CMS Web site. ref OF 4 OL4L  The link is:
A90483 -
A90484 -                        http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/table4c_101705.zip
A90486 -  ..
A90487 - This source shows CBSA code for San Francisco is 41884 and wage index
A90488 - is 1.4740   GAF - 1.3043
A90490 -  ..
A90491 - ACR article guidance continues...
A90492 -
A90493 -                 To locate the APC payment rate go to the CMS Web site.
A90494 -                 The link is:
A90495 -
A90496 -                        http://new.cms.hhs.gov/apps/ama/license.asp?file=/hospitaloutpatientpps/downloads/cms-1501-fc_addb.zip
A90498 -                  ..
A90499 -             3.  To adjust for wage differences across geographic
A90500 -                 areas, the labor-related portion of the payment rate
A90501 -                 (60 percent) is wage adjusted by the wage index value.
A90502 -                 In order to calculate the wage adjusted payment, you
A90503 -                 must first separate the APC payment amount into 60
A90504 -                 percent and 40 percent.  For example: for CPT Code
A90505 -                 70553, MRI brain w/o and w/dye, the APC payment amount
A90506 -                 is $506.  Multiply the $506 amount by 60% = $304.
A90507 -                 Next, multiply the $506 amount by 40% = $202.
A90508 -                 ref OF 4 KO6H
A90510 -                  ..
A90511 -             4.  The second step is to multiply the labor-related
A90512 -                 portion of the payment rate (60 percent) by the wage
A90513 -                 index.  This is the preliminary adjustment.  For
A90514 -                 example: the wage index for CBSA code 10420, Akron,
A90515 -                 OH, is 0.8970.  Multiply the 60 percent amount, which
A90516 -                 is $304, by 0.8970 = $273.  The $273 is the
A90517 -                 preliminary adjustment amount. ref OF 4 KP3P
A90519 -                  ..
A90520 -             5.  The final step is to add the preliminary adjustment
A90521 -                 amount to the remaining 40 percent APC payment amount.
A90522 -                 For example: add $273 (preliminary adjustment amount)
A90523 -                 to $202 (remaining 40% APC amount) = $475.  The wage
A90524 -                 adjusted payment for CPT code 70553, and CBSA 10420,
A90525 -                 is $475. ref OF 4 KP3V
A90527 -                  ..
A90528 -             6.  This means that the nationally averaged hospital
A90529 -                 outpatient payment rate for a MRI brain w/o and w/dye
A90530 -                 is $506 and the geographically adjusted amount that
A90531 -                 the hospitals get from Medicare in Akron, OH is $475.
A90532 -                 ref OF 4 KP4R
A90534 -                  ..
A90535 -                 Please feel free to utilize the attached template in
A90536 -                 order to calculate the wage adjusted APC payment.  You
A90537 -                 will need to know the CBSA code for your area, the CPT
A90538 -                 code(s) for the procedure(s) you're interested in
A90539 -                 determining an adjusted payment for, the APC payment
A90540 -                 for each procedure, and the wage index for your area.
A90541 -                 ref OF 4 KP47
A90542 -
A90543 -
A90544 -
A90545 -
A906 -

SUBJECTS
CMS Announcement Deductible Medigap High Deductible Options Calendar

AU03 -
AU0401 -  ..
AU0402 - Medigap Medicare Supplemental Secondary Insurance Pays Coinsurance
AU0403 -
AU0405 -  ..
AU0406 - Medicare publications...
AU0407 -
AU0408 -        Medicare and Clinical Trials
AU0409 -
AU0410 -            800 633 4227
AU0411 -
AU0412 -              http://www.medicare.gov/Publications/Pubs/pdf/02226.pdf
AU0414 -         ..
AU0415 -        Will my Medigap (Medicare Supplement Insurance) policy pay for
AU0416 -        my coinsurance and deductibles if I am in a clinical trial?
AU0418 -         ..
AU0419 -        If the routine costs of your trial are covered by Medicare,
AU0420 -        then your Medigap policy must pay coinsurance amounts for those
AU0421 -        costs.  If your Medigap policy also covers deductibles and
AU0422 -        excess charges, it must also pay these amounts for routine
AU0423 -        services.
AU0424 -
AU0425 -            [On 071128 Kaiser Appeals Committee approved payment for
AU0426 -            Millie's care on referral to UCSF. ref SDS 28 JZ5R
AU0428 -  ..
AU0429 - A CMS announcement dated 021022 seems to support requirements for
AU0430 - secondary insurance, which Millie has with Kaiser Senior Advantage, to
AU0431 - pay for hospital coinsurance...
AU0432 -
AU0433 -        A Medicare supplemental, or Medigap, policy is private health
AU0434 -        insurance that a beneficiary may purchase to cover certain
AU0435 -        expenses that Medicare does not cover.  For example, the
AU0436 -        beneficiary is responsible for deductibles and coinsurance
AU0437 -        amounts for both Part A (hospital insurance) and Part B
AU0438 -        (supplementary medical insurance) of the Medicare program.  In
AU0439 -        addition, Medicare generally does not cover outpatient
AU0440 -        prescription drugs, custodial nursing home care, or preventive
AU0441 -        care.  A beneficiary must either pay the full cost of these
AU0442 -        services, or he or she may purchase additional private health
AU0443 -        insurance to help pay these costs.  Medigap policies offer
AU0444 -        coverage for some or all of the deductibles and coinsurance
AU0445 -        amounts required by Medicare.  Additionally, Medigap policies
AU0446 -        may provide coverage for some services, such as outpatient
AU0447 -        prescription, ref OF 1 G129
AU0448 -
AU0450 -  ..
AU0451 - Kaiser Senior Advantage supplemental insurance must meet specific
AU0452 - requirements...
AU0454 -         ..
AU0455 -        The Omnibus Budget Reconciliation Act of 1990 (OBRA '90)
AU0456 -        amended the [Social Security] Act by requiring that Medigap
AU0457 -        benefits be standardized... ref OF 1 WO92
AU0459 -         ..
AU0460 -        There are ten benefit packages, designated as plans "A" through
AU0461 -        "J".  Plan "A" is the basic benefit package.  It covers
AU0462 -        Medicare Part A hospital coinsurance...; Medicare Part B
AU0463 -        coinsurance (generally 20 percent of the Medicare-approved
AU0464 -        amount or, in the case of hospital outpatient department
AU0465 -        services under a prospective payment system, the applicable
AU0466 -        copayment)...  Medigap Plans "B" through "J" contain this basic
AU0467 -        benefit package, as well as different combinations of
AU0468 -        additional benefits. ref OF 1 WO96
AU0469 -
AU0471 -  ..
AU0472 - Statute governing Medicare may be...
AU0473 -
AU0474 -        Title 42--Public Health
AU0475 -
AU0476 -        CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES,
AU0477 -        DEPARTMENT OF HEALTH AND HUMAN SERVICES
AU0479 -         ..
AU0480 -        PART 419--PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT
AU0481 -        DEPARTMENT SERVICES
AU0482 -
AU0483 -              http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr419_02.html
AU0484 -
AU0486 -  ..
AU0487 - Another source....
AU0488 -
AU0489 -        Justia US Laws
AU0490 -
AU0491 -              http://law.justia.com/us/cfr/title42/42-2.0.1.2.19.html
AU0492 -
AU0494 -  ..
AU0495 - Kaiser has a document with a telephone number for Medicare...
AU0496 -
AU0497 -        Kaiser Permanente Senior Advantage
AU0498 -        Evidence of Coverage for
AU0499 -        CITY OF SAN JOSE
AU0500 -        Purchaser ID: 887 Contract: 4 Version: 46 EOC Number: 29
AU0501 -        January 1, 2004 through December 31, 2004
AU0502 -
AU0503 -              http://www.sjretirement.com/Uploads/Fed/Medicare_KP_Permanent_Sr_Advantage.pdf
AU0505 -         ..
AU0506 -        800-443-0815
AU0507 -
AU0509 -         ..
AU0510 -        Medigap Kaiser Senior Advantage Customers Cancel Duplication
AU0511 -        Important information about Medicare supplement (Medigap)
AU0512 -        policies. (page 3)
AU0514 -         ..
AU0515 -        If you have a Medicare supplement (Medigap) policy, you may
AU0516 -        consider canceling it after we send you written confirmation of
AU0517 -        your enrollment in Senior Advantage.  However, if you later
AU0518 -        disenroll from Senior Advantage, you may not be able to have
AU0519 -        your Medigap policy reinstated.
AU0520 -
AU0521 -            [On 070924 letter notifies UCSF Millie makes 2 insurance
AU0522 -            payments, Kaiser represented Senior Advantage supplements
AU0523 -            Medicare, and cites this research showing support.
AU0524 -            ref SDS 16 UL5Y
AU0526 -             ..
AU0527 -            [On 070924 UCSF argues Kaiser Senior Advantage does not
AU0528 -            replace Medigap coverage. ref SDS 16 N45P
AU0530 -             ..
AU0531 -            [On 070927 seems conflicting with Kaiser documentation
AU0532 -            saying on page 4 that Senior Advantage is not supplemental,
AU0533 -            "Medigap," coverage, ref SDS 17 1F6L; Kaiser telling
AU0534 -            patients to cancel Medigap, ref SDS 0 EZ56, aligns with
AU0535 -            Kaiser representations to Millie that Senior Advantage
AU0536 -            supplements Medicare, that she did not need additional
AU0537 -            insurance to maintain continuity of treatment for cancer
AU0538 -            begun in 2002. ref SDS 17 4A9J
AU0540 -             ..
AU0541 -            [On 071018 AARP article reports widespread confusion about
AU0542 -            differences between Medigap supplemental Medicare policies
AU0543 -            and HMO insurance coverage due to misrepresentations
AU0544 -            selling managed care insurance cause beneficiaries to incur
AU0545 -            significant extra charges. ref SDS 23 CR6T
AU0547 -             ..
AU0548 -            [On 071116 primary care physician reports re-submitting
AU0549 -            authorization for Millie's treatment on referral at UCSF,
AU0550 -            ref SDS 27 BO6L; indicates Kaiser's accepts responsibility
AU0551 -            for Medigap coverage. ref SDS 27 EN78
AU0553 -             ..
AU0554 -            [On 071128 Kaiser Appeals Committee approved payment for
AU0555 -            Millie's care on referral to UCSF. ref SDS 28 JZ5R
AU0556 -
AU0558 -         ..
AU0559 -        Clinical Trial Provider Must Explain Charges
AU0560 -        Special Note about Services Associated with Clinical Trials
AU0561 -
AU0562 -        Original Medicare will pay for certain Services related to
AU0563 -        qualifying clinical trials that we do not cover.  You should
AU0564 -        continue to come to Plan Providers for all covered Services
AU0565 -        that are not part of the clinical trial.  Medicare will pay for
AU0566 -        many, but not all, Services associated with qualifying clinical
AU0567 -        trials.  You should ask the clinical trial provider if the
AU0568 -        clinical trial qualifies for Medicare payments and what
AU0569 -        Medicare coinsurance and other out-of-pocket expenses you will
AU0570 -        have to pay for related Services.  Original Medicare does not
AU0571 -        require that you get a referral from a Plan Physician to join a
AU0572 -        qualifying clinical trial.  However, you should tell us before
AU0573 -        you join a clinical trial outside of Kaiser Permanente so we
AU0574 -        can keep track of your Services.  For more information on
AU0575 -        Medicare payments for clinical trials and which trials qualify,
AU0576 -        please call Medicare directly at 1-800-MEDICARE
AU0577 -        (1-800-633-4227) (TTY 1-877-486-2048).
AU0579 -  ..
AU0580 - Kaiser's guidance to ask clinical trial provider to explain charges in
AU0581 - advance of performing services aligns with documentation from Kaiser
AU0582 - Member Services on 070829. ref SDS 9 SF52
AU0584 -  ..
AU0585 - This is a hollow notice shown by Millie's case where UCSF advises 8
AU0586 - months after the fact that coinsurance costs are only known by Kaiser,
AU0587 - reported on 070830. ref SDS 10 WU5N
AU0588 -
AU0589 -              [On 070927 Kaiser EOC Section 7 says clinical trial
AU0590 -              service provider must explain charges for coinsurance.
AU0591 -              ref SDS 0 416K
AU0593 -  ..
AU0594 - Kaiser seems to suggest that because Medicare encourages patients to
AU0595 - participate in clinical trials for purposes of advancing science that
AU0596 - may help future patients, including cost containment, per above,
AU0597 - ref SDS 0 4Q3I, the patient's right to self-refer shields Kaiser from
AU0598 - responsibility for payment of treatment determined by Kaiser to be
AU0599 - medically necessary for effective care, as occurred in Millie's case,
AU0600 - shown by case study on 070830, ref SDS 10 LQ5I, and further citing the
AU0601 - study on 070130. ref SDS 7 2X6L
AU0602 -
AU0603 -              [On 070927 16 legal issues indicate Kaiser obligated to
AU0604 -              pay for prescribed treatment in this case. ref SDS 17
AU0605 -              WU6M
AU0606 -
AU0607 -
AU0608 -
AU0609 -
AU0610 -
AU0611 -
AU07 -

SUBJECTS
Kaiser Senior Advantage Pays Clinical Trials Referral Doctor Authori

BL03 -
BL04 - 1630
BL0501 -  ..
BL0502 - Authorization for Treatment Missing from Kaiser's Computer
BL0503 - Kaiser Senior Advantage Pays Costs of Referrals Clinical Trials
BL0504 -
BL0505 - Called Virginia at Kaiser Senior Advantage...
BL0506 -
BL0507 -        800-443-0815
BL0509 -  ..
BL0510 - This call was interrupted by approximately 5 research efforts while
BL0511 - Virginia consulted with colleagues, supervisors, and references
BL0512 - sources.
BL0514 -  ..
BL0515 - Asked about Kaiser paying for coinsurance on Millie's clinical trial
BL0516 - at UCSF, per Medicare regulations shown above saying that secondary
BL0517 - insurance must pay this expense. ref SDS 0 EZ8R  In this case,
BL0518 - Millie's secondary insurance is with Kaiser Senior Advantage.
BL0519 - Research indicates that Kaiser Senior Advantage provides Medigap
BL0520 - coverage. ref SDS 0 EZ56
BL0522 -  ..
BL0523 - Virginia advised that Kaiser routinely pays for costs of referrals,
BL0524 - and the patient retains responsibility for onging copayments, as if
BL0525 - treatment were provided at a Kaiser facility.
BL0527 -  ..
BL0528 - Virginia feels the primary care physician should have submitted a
BL0529 - signed authorization for Millie to get treatment, and that would
BL0530 - permit Kaiser to cover Millie's costs, except for co-payments.
BL0532 -  ..
BL0533 - Virginia said there was a mistake in Millie's file, because she cannot
BL0534 - find a record of the doctor submitting authorization for Millie's
BL0535 - treatment at UCSF.
BL0537 -  ..
BL0538 - Virginia said that Kaiser insists on thorough documentation to verify
BL0539 - compliance with requirements and commitments.  She feels in this case
BL0540 - the doctor made a mistake.
BL0542 -  ..
BL0543 - We reviewed the letter Millie received from the doctor on 070119
BL0544 - stating that authorization was submitted. ref SDS 5 LW9N
BL0546 -  ..
BL0547 - Virginia said there must be some mistake then because her computer
BL0548 - screen does not show the authorization.  Virginia said Millie should
BL0549 - ask her doctor about this, because the doctor is the patient's primary
BL0550 - contact with Kaiser.
BL0551 -
BL0552 -        [On 071030 Kaiser MCRC Unit advises investigation cannot
BL0553 -        determine what happened to doctor's authoriztion submitted on
BL0554 -        070119, plans to have doctor re-submit authorization for
BL0555 -        referral work at UCSF. ref SDS 25 FM67
BL0557 -         ..
BL0558 -        [On 071116 primary care physician reports re-submitting
BL0559 -        authorization for Millie's treatment on referral at UCSF,
BL0560 -        ref SDS 27 BO6L; indicates Kaiser's accepts responsibility for
BL0561 -        Medigap coverage. ref SDS 27 EN78
BL0563 -         ..
BL0564 -        [On 071128 Kaiser Appeals Committee approved payment for
BL0565 -        Millie's care on referral to UCSF. ref SDS 28 JZ5R
BL0567 -  ..
BL0568 - Requested letter from Virginia documenting understandings today that
BL0569 - would support follow up by Millie.
BL0571 -  ..
BL0572 - Virginia said her boss at Kaiser does not permit the staff to access
BL0573 - patient records to verify communications between Kaiser and patients.
BL0574 - Neither can Virginia receive communications from patients and members
BL0575 - to avoid misunderstandings by documenting communications in telephone
BL0576 - calls; and, Virginia and her colleagues in the customer service
BL0577 - department are not permitted to submit documentation to customers and
BL0578 - patients confirming representations of findings and recommendations on
BL0579 - solving complex problems.   This aligns with failure of Kaiser to
BL0580 - confirm understandings from telephone call with Pam in Kaiser's
BL0581 - Outside Referral Department on 070124. ref SDS 6 K184
BL0582 -
BL0583 -
BL0584 -
BL0585 -
BL06 -

SUBJECTS
Default Null Subject Account for Blank Record

BM03 -
BM0401 -  ..
BM0402 - Notify Millie UCSF Substantially Reduced Claim for Referral Services
BM0403 -
BM0404 - Submitted letter to Millie traveling on vacation in Europe, and
BM0405 - saying...
BM0406 -
BM0407 -    1.  Subject: Clinical Trial Millie Buck UCSF Account 45772381
BM0408 -        Date: Mon, 17 Sep 2007 00:10:37 -0700
BM0412 -         ..
BM0413 -    2.  Mil,
BM0415 -         ..
BM0416 -    3.  Just a quick update with partially good news.  UCSF has
BM0417 -        accepted your position that you owe nothing except for
BM0418 -        coinsurance.  ref SDS 0 595P  They have reduced their bill down
BM0419 -        from about $6K to $1.2K. ref SDS 0 J14R  Again guessing at this
BM0420 -        time, your annual cost above insurance premiums for treatment
BM0421 -        at UCSF on the cetuximab clinical trial looks now like about
BM0422 -        $2K [per above, instead of $10K that UCSF initially claimed.
BM0423 -        ref SDS 0 WO4O
BM0424 -
BM0425 -            [On 071006 Millie received additional billings from UCSF
BM0426 -            that indicate total charges would be in the range of $15K -
BM0427 -            $20K per year. ref SDS 20 PRWW
BM0429 -         ..
BM0430 -    4.  I don't know if $2K per year is in the ballpark of normal
BM0431 -        co-payments if you were treated at Kaiser.  If so, then maybe
BM0432 -        we should declare victory and move on.  At this time, UCSF has
BM0433 -        not explained nor demonstrated the basis for calculating
BM0434 -        coinsurance amounts.
BM0436 -         ..
BM0437 -    5.  Tomorrow I will ask for backup on how coinsurance is
BM0438 -        calculated.  My guess is this can be further reduced, but we'll
BM0439 -        see.
BM0440 -
BM0441 -            [On 070919 responded to UCSF letter on 070912 received
BM0442 -            today, ref SDS 15 EZ5J, and request meeting with Kaiser to
BM0443 -            develop referral coordination plan with solid footing for
BM0444 -            continuing Millie's referral treatment. ref SDS 15 I55W
BM0446 -         ..
BM0447 -    6.  In any case, congratulations on getting a favorable response to
BM0448 -        eliminate extra charges.
BM0449 -
BM0450 -            [On 071128 Kaiser Appeals Committee approved payment for
BM0451 -            Millie's care on referral to UCSF. ref SDS 28 JZ5R
BM0452 -
BM0459 -
BM0460 -
BM0461 -
BM0462 -
BM0463 -
BM0464 -
BM0465 -
BM0466 -
BM0467 -
BM0468 -
BM0469 -
BM0470 -
BM0471 -
BM0472 -
BM0473 -
BM0474 -
BM05 -