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

SUBJECTS
Coinsurance Clinical Trials Not Chargable to Patient on Referral fro

5303 -
5303 -    ..
5304 - Summary/Objective
5305 -
530501 - Follow up ref SDS 10 0000.
530502 -
530503 -
530504 -
530505 -
530506 -
530507 -
530508 -
530509 -
530511 -  ..
5306 -
5307 -
5308 - Progress
5309 -
530901 - UCSF Substantial Progress Resolving Clinical Trial Payment Issues
530902 -
530903 - Follow up ref SDS 10 EZ5J, ref SDS 9 XH5H.
530904 -
530905 - Submitted a letter, ref DIT 1 0001, to UCSF responding to Bob's
530906 - letter, ref SDS 10 EZ5J, dated 070912 and received on 070917, which
530907 - reports UCSF has reduced the claim, ref SDS 10 595P, from $10K per
530908 - year to about $2K per year. ref SDS 10 WO4O
530910 -         ..
530911 -    1.  Thanks very much for your letter on September 12th reporting
530912 -        that UCSF has reduced the claim against Millie, ref SDS 10
530913 -        595P, from $4,254.12 to now the amount of $1,506.60, as shown
530914 -        in the spreadsheet you attached in your letter on September 12.
530915 -        ref SDS 10 WP5I  Since Millie made interim payment of $312.08
530916 -        on September 6th, you show a current remaining obligation for
530917 -        coinsurance of $1,194.52. ref SDS 10 J14R  Millie is grateful
530918 -        for substantial progress recognizing her entitlement to
530919 -        coverage of all costs for routine care in the clinical trial,
530920 -        as set out in the letter to UCSF on September 9. ref SDS 9 6O6Q
530921 -        Your letter on the 12th confirms that at this time, there is
530922 -        only a question about coinsurance.  To show good faith, Millie
530923 -        made an interim payment [reported on September 6, 2007],
530924 -        ref SDS 8 EB3P, subject to justification of these charges.
530925 -        [noted in Millie's letter to UCSF on September 4, 2007.
530926 -        ref SDS 7 6R4W, ref DIT 1 0001
530927 -
530928 -            [On 070924 UCSF responds cites Millie's insurance coverage
530929 -            Kaiser Senior Advantage. ref SDS 11 EZ5J
530931 -         ..
530932 -    2.  Your letter on the 12th [received on 070917] submits an extract
530933 -        of CMS regulations section 69.9 that say in part on page 8...
530935 -         ..
530936 -        "Managed care enrollees are liable for the coinsurance amounts
530937 -        applicable to services paid under Medicare fee for service
530938 -        rules. ref SDS 10 596Q, ref DIT 1 GE7G
530940 -         ..
530941 -        The clinical trial coding requirements for managed care
530942 -        enrollee claims are the same as those for regular Medicare fee
530943 -        for service claims."
530945 -         ..
530946 -    3.  Legislative history of Medicare policy encourages beneficiaries
530947 -        to purchase in the private market supplemental, secondary
530948 -        insurance to pay for coinsurance and deductibles not covered by
530949 -        Medicare.  Title 42 section 419.40 allows hospitals to
530950 -        advertise and otherwise compete for business by offering
530951 -        reduced rates of coinsurance, which is authorized by section
530952 -        419.42.  Notice as well that section 419.20 seems to set
530953 -        limitations on the annual amount beneficiaries must pay for
530954 -        coinsurance... see review on 070919. ref SDS 10 6G4N,
530955 -        ref DIT 1 GE8L
530957 -         ..
530958 -    4.  Since Kaiser presented Millie with Medicare as the primary
530959 -        surety, Millie's payments of premiums to Kaiser make Kaiser her
530960 -        secondary supplemental carrier for the transaction with UCSF.
530961 -        Medicare calls this Medigap coverage, and seems to indicate
530962 -        this must pay for coinsurance in clinical trials. ref SDS 10
530963 -        NY5H, ref DIT 1 GE9N
530964 -
530965 -            [On 070924 UCSF responds cites Millie's insurance coverage
530966 -            Kaiser Senior Advantage. ref SDS 11 EZ5J
530968 -         ..
530969 -    5.  CMS guidance on Medicare and clinical trials states.
530970 -
530971 -           http://www.medicare.gov/Publications/Pubs/pdf/02226.pdf
530973 -         ..
530974 -        "If the routine costs of your trial are covered by Medicare,
530975 -        then your Medigap policy must pay coinsurance amounts for those
530976 -        costs.  If your Medigap policy also covers deductibles and
530977 -        excess charges, it must also pay these amounts for routine
530978 -        services." ref SDS 10 ZC9G, ref DIT 1 9A5N
530980 -         ..
530981 -    6.  We should try to meet with Kaiser and work through coordination
530982 -        of these issues in order to get a solid footing going forward.
530983 -        ref DIT 1 GE5N
530985 -  ..
530986 - Implements letter to Millie on 070917 planning follow up to resolve
530987 - coinsurance billing mistake. ref SDS 10 SM6Q
530988 -
530990 -  ..
530991 - Letter to UCSF continues...
530992 -
530993 -    7.  Thanks again for working hard to assist Millie.  Your letter on
530994 -        September 12 helps implement planning for her care by Doctor
530995 -        Rugo and [the primary care physician at Kaiser] on December 30,
530996 -        2006. ref SDS 1 3X6K, ref DIT 1 GE5S
530998 -         ..
530999 -    8.  She's back from vacation, and ready to resume treatment
531000 -        tomorrow.  Millie is also scheduled to meet with the primary
531001 -        care physician, Doctor Johnson, at Kaiser the next day on
531002 -        Friday for his case follow up.  Hopefully, we can keep moving
531003 -        ahead. ref DIT 1 GE6O
531004 -
531005 -
531006 -
531007 -
531008 -
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5311 -