CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0503 -
0503 -    ..
0504 - Summary/Objective
0505 -
050501 - Follow up ref SDS 26 O492, ref SDS 25 SS4I.
050502 -
050503 -
050504 -
050505 -
050506 -
050507 -
050509 -  ..
0506 -
0507 -
0508 - Progress
0509 -
050901 - CMS Medicare Kaiser Cannot Transfer Costs Prescribed Care to Patient
050902 - Managed Care Pays for Prescribed Treatment in Clinical Trials
050903 -
050904 - Last week on 070917 Catherine Windfield Jones with CMS Operations
050905 - Group was listed on the Internet as a contact for policy issues on
050906 - Medigap...
050908 -                     ..
050909 -                    410 786 6674
050911 -  ..
050912 - At that time on 070917 left a message for Cathy to ask about Kaiser
050913 - senior advantage paying coinsurance expense for treatment Kaiser
050914 - prescribed in a clinical trial. ref SDS 25 SY6K
050916 -  ..
050917 - A few days ago, Cathy called back and said she referred the matter to
050918 - a Kaiser specialist.  Her feeling seemed to be that Kaiser should pay
050919 - for Millie's treatment on clincial trial prescribed by the doctor, per
050920 - Medicare guidance reported on 070917, ref SDS 25 WQ3G, and Kaiser's
050921 - notice to members they should cancel their Medigap coverage after
050922 - receiving verification that Kaiser Senior Advantage becomes effective.
050923 - ref SDS 25 EZ56
050924 -
050925 -     [On 071003 called Cathy; she was traveling, her voice mail
050926 -     referred calls to James Mayhew. ref SDS 28 KA5J
050928 -      ..
050929 -     [On 071003 called James Mayhew at CMS, and he requested a letter
050930 -     to review public issues in Millie's case. ref SDS 28 0E4K
050932 -  ..
050933 - When we returned today from UCSF for Millie's weekly treatment, there
050934 - was a message from....
050935 -
050936 -                         Julyann???
050937 -
050938 -                         415 744 3617
050940 -  ..
050941 - Called the number and talked to Lee Faleafine.
050942 -
050943 -        [On 071003 Jullin called back and is working on Millie's case.
050944 -        ref SDS 28 7G5G
050946 -  ..
050947 - Asked Lee about CMS Medicare regulations encouraging patients to
050948 - particiapte in clinical trials that advance medical science.  Can
050949 - managed care service providers (HMO's) who prescribe treatments
050950 - patients need with therapies provided in clinical trials, called out
050951 - in Kaiser's Senior Advantage EOC section 2, reviewed below,
050952 - ref SDS 0 RY5H, transfer their duty to pay for covered oncology
050953 - services to Medicare 80% and patient coinsurance 20%, as reviewed
050954 - below? ref SDS 0 WV5G
050956 -  ..
050957 - Lee asked about Millie's case.
050959 -  ..
050960 - Millie is 72 years old and stage IV cancer patient, being treated for
050961 - 3rd relapse of IBC at UCSF Medical Center on clinical trial with
050962 - cetuximab on referral from Kaiser in Walnut Creek, CA.
050964 -  ..
050965 - Background on referral is shown in a case study on 070130. ref SDS 17
050966 - 2X6L  On 061230 the doctor said Kaiser would pay any costs not covered
050967 - by the trial. ref SDS 13 3X6K  Documentation on referral is listed in a
050968 - case study on 070830. ref SDS 20 LQ5I
050970 -  ..
050971 - Six months or so later, Millie began getting invoices from UCSF
050972 - seeking recovery for extra expenses, initially totaling about $10K per
050973 - year, which is about 56% of Medicare approved payments, contrary to
050974 - agreement on 061230 for Kaiser to pay costs of the work, and further
050975 - conflicting with review on 070917 showing coinsurance should be a
050976 - percentage above 20% minimum. ref SDS 25 SS4I  Meeting with UCSF
050977 - revealed about $2K of the extra cost is for "coinsurance," reported on
050978 - 070830. ref SDS 20 W06L
050980 -  ..
050981 - On 070917 Millie received a letter from UCSF dated 070912 that
050982 - indicated UCSF eliminated some charges, and revised the bill to about
050983 - $2K per year. ref SDS 25 WP5I  Since then Millie continues to get
050984 - invoices that seem much higher, and refuses to state the amount of
050985 - charges until after work is performed, which prevents the patient from
050986 - approving the work, and budgeting for payments.  Additionally, charges
050987 - exceed terms of agreement with Kaiser, in that Kaiser seeks to
050988 - transfer all costs not paid by Medicare to the patient, per below.
050989 - ref SDS 0 WV5G
050991 -  ..
050992 - UCSF's letter cited CMS regulation 69.9 to justification overcharging
050993 - Millie for medical services which Kaiser agreed to pay, also, reviewed
050994 - on 070917. ref SDS 25 596Q
050996 -  ..
050997 - Lee suggested sending a letter to CMS email address...
050998 -
050999 -                rosfodhpp@cms.hhs.gov
051000 -
051001 - ...for review of issues presented by the record in Millie's case, per
051002 - below. ref SDS 0 WU6M
051003 -
051004 -        [On 071002 submitted letter to Lee explaining issues for CMS to
051005 -        address in Millie's case. ref SDS 27 KA5J
051006 -
051007 -
051008 -
051009 -
0511 -

SUBJECTS
Kaiser Senior Advantage Individual Plan Membership Agreement and Dis

2103 -
210401 -  ..
210402 - Kaiser Senior Advantage Transmittal to Customers
210403 -
210404 - Millie found a document today which she received from Kaiser in
210405 - December or January.  There is a transmittal letter with an
210406 - inconclusive date of January 2007.
210407 -
210408 -        [On 071006 Paula checking for changes in EOC from 2004 to
210409 -        2007. ref SDS 30 453G
210411 -  ..
210412 - Millie does not know when the document was received, either in
210413 - November or December of 2007 so that customers have time to inquire
210414 - and make arrangements in the event of disagreement with proposed
210415 - terms, or in January, February, March 2007.  The document has no
210416 - received date markings, stamp, etc.
210417 -
210418 -    1.  Kaiser Permanente Senior Advantage
210419 -        Kaiser Foundation Health Plan, Inc.
210420 -        393 East Walnut Street
210421 -        Pasadena, CA  91188
210423 -         ..
210424 -    2.  January 2007
210426 -         ..
210427 -    3.  Dear Kaiser Permanente Member:
210429 -  ..
210430 - EOC Evidence of Coverage Kaiser Benefits Clinical Trials Medigap
210431 - Evidence of Coverage EOC Kaiser Benefits Clinical Trials Medigap
210432 -
210433 -
210434 -        Thank you for your continued membership in Kaiser Pemmanente
210435 -        Senior Advantage.  The enclosed Disclosure for and Evidence of
210436 -        Coverage (DF/EOC) describes your coverage for 2007.  Please
210437 -        read this DF/EOC completely so that you can take full advantage
210438 -        of your health plan benefits.
210440 -         ..
210441 -    4.  If you have any questions about this information please call
210442 -        our Member Service Call Center.  Our Representatives are
210443 -        available toll free at 1 800 443 0815 (TTY 1 800 777 1730),
210444 -        seven days a week 8 am to 8 pm.
210446 -         ..
210447 -    5.  Sincerely,
210448 -
210449 -        Denise Hanson
210450 -        Vice President, Medicare & State Programs
210452 -         ..
210453 -    6.  Kaiser Permanente is a Medicare Advantage Organization with a
210454 -        Medicare contract.
210456 -         ..
210457 -        The next page says...
210458 -
210459 -
210460 -
210461 -    1.  Kaiser Permanente Senior Advantage Scope of Services
210462 -
210463 -        2007 Individual Plan Membership Agreement and Disclosure Form
210464 -        and Evidence of Coverage (DF/EOC)
210466 -         ..
210467 -        January 1, 2007 through December 31, 2007
210469 -  ..
210470 - Kaiser Senior Advantage Page i says in part...
210471 -
210472 -    1.  Welcome to Kaiser Permanente Senior Advantage
210473 -
210474 -        We are pleased that you are enrolled (or are considering
210475 -        enrollment) in Kaiser Permanente Senior Advantage (Senior
210476 -        Advantage), a Medicare Advantage Plan for people with Medicare.
210478 -         ..
210479 -    2.  When you enroll in Senior Advantage, you are getting your care
210480 -        through the Kaiser Permanente Medical Care Program (Kaiser
210481 -        Permanente).  Kaiser Permanente is comprised of Kaiser
210482 -        Foundation Health Plan, Inc. (Health Plan), Kaiser Foundation
210483 -        Hospitals, and The Permanente Medical Group, Inc.
210484 -
210485 -
210486 -
2105 -

SUBJECTS
Medigap Supplemental Coverage Medicare Excluded Kaiser Senior Advant

4003 -
400401 -         ..
400402 -        Medigap Supplemental Coverage Excluded Senior Advantage
400403 -        Supplemental Medigap Coverage Excluded Senior Advantage
400404 -
400405 -
400406 - Kaiser Senior Advantage Page i continues...
400407 -
400408 -    3.  Health Plan, a Health Maintenance Organization (HMO) and a
400409 -        Medicare Advantage Organization, offers Senior Advantage, a
400410 -        Medicare Advantage Plan for people with Medicare.  Senior
400411 -        Advantage is not a Medigap or supplemental Medicare insurance
400412 -        policy; it is a Medicare Advantage Plan.
400414 -  ..
400415 - Kaiser's disclaimer of supplemental coverage is stated again in
400416 - section 2 page 4, ref SDS 0 1F6L, reviewed below in relation to
400417 - Millie's patient history. ref SDS 0 4A9J
400418 -
400419 -            [On 071006 Paula with Kaiser MCRC unit checking for changes
400420 -            in EOC from 2004 to 2007. ref SDS 30 453G
400422 -             ..
400423 -            [On 071215 article SF Chronicle reports challenges getting
400424 -            treatment clinical trials at Kaiser. ref SDS 41 E75J
400426 -  ..
400427 - An issue for legal review is whether this disclaimer has been obviated
400428 - by Kaiser's conduct, ref SDS 0 MS3K, including Kaiser sales rep
400429 - telling the patient Kaiser would provide continuing care for a
400430 - continuing condition, per below, ref SDS 0 H75F, and including public
400431 - notices that attract customers by saying to cancel Medigap coverage
400432 - after signing up with Senior Advantage? ref SDS 0 WX6K
400433 -
400434 -
400435 -
400436 -
400437 -
400438 -
400439 -
4005 -

SUBJECTS
Default Null Subject Account for Blank Record

4103 -
410401 -  ..
410402 - Kaiser Senior Advantage Page i continues...
410403 -
410404 -    4.  This DF/EOC explains how to get your Medicare Services through
410405 -        Senior Advantage (except for hospice care for Members with
410406 -        Medicare Parts A and B and qualifying clinical trials, which
410407 -        are covered directly by Original Medicare as described in
410408 -        Section 7).
410410 -         ..
410411 -    5.  About Kaiser Permanente
410413 -         ..
410414 -        Kaiser Permanente provides Services directly to our Members
410415 -        through an integrated medical care program.  Health Plan, Plan
410416 -        Hospitals, and the Medical Group work together to provide our
410417 -        Members with quality care.  Our medical care program gives you
410418 -        access to all of the covered Services you may need, such as
410419 -        routine care with your own personal Plan Physician, hospital
410420 -        care, laboratory and pharmacy Services, Emergency Care, Urgent
410421 -        Care, and other benefits.  Plus, our preventive care programs
410422 -        and healthy living (health education) classes offer you great
410423 -        ways to protect and improve your health.
410425 -         ..
410426 -    6.  We provide covered Services to Members using Plan Providers
410427 -        located in our Service Area, which is described in Section 2.
410428 -        You must receive all covered care from Plan Providers inside
410429 -        our Service Area, except as otherwise described in this DF/EOC.
410431 -  ..
410432 - Kaiser Senior Advantage Page ii says in part...
410433 -
410434 -        Please read this DF/EOC so that you will know from whom or what
410435 -        group of providers you may get health care.  It is important to
410436 -        familiarize yourself with your coverage by reading this DF/EOC
410437 -        completely, so that you can take full advantage of your Health
410438 -        Plan benefits.  Also, if you have special health care needs,
410439 -        please carefully read the sections that apply to you.
410440 -
410442 -         ..
410443 -    7.  Please tell us how we are doing
410444 -
410445 -        We want to hear from you about how we are doing as your health
410446 -        plan.  Your comments are always welcome.  You can call or write
410447 -        to us at any time (Section 1 of this DF/EOC tells how to
410448 -        contact us).  From time to time, we do surveys that ask our
410449 -        Members to tell about their experiences with Kaiser Permanente.
410450 -        If you are contacted, we hop you will participate in a Member
410451 -        satisfaction survey.  Your answer to the survey questions will
410452 -        help us know what we are doing well and where we need to
410453 -        improve.
410454 -
410456 -  ..
410457 - Kaiser Senior Advantage section 2 Page 4 says in part...
410458 -
410459 -        Section 2
410460 -
410461 -    1.  What is Kaiser Permanente Senior Advantage
410462 -
410463 -        Senior Advantage provides Services covered by Medicare
410464 -        (including Medicare Part D prescription drug coverage described
410465 -        in Section 6), except for hospice care for Members with
410466 -        Medicare Parts A and B and qualifying clinical trials, which
410467 -        are covered directly by Medicare as described in Section 7.
410468 -        ref SDS 0 1F92  Senior Advantage is for Members entitled to
410469 -        Medicare, providing the advantages of combined Medicare and
410470 -        Health Plan benefits.  Enrollment in Senior Advantage means
410471 -        that you are automatically enrolled in Medicare Part D.
410472 -
410473 -
410474 -
4105 -

SUBJECTS
Medigap Supplemental Coverage Medicare Excluded Kaiser Senior Advant

6203 -
620401 -  ..
620402 - Kaiser HMO Managed Care Not Medigap Supplemental Medicare Coverage
620403 -
620404 -
620405 -    2.  Senior Advantage is a Medicare Advantage Plan offered by Health
620406 -        Plan (an HMO) and a Medicare Advantage Organization) to people
620407 -        with Medicare.  As a Senior Advantage Member, you are getting
620408 -        your Medicare benefits through Kaiser Permanente (except for
620409 -        hospice are for Members with Medicare Parts A and B and
620410 -        qualifying clinical trials, which are covered directly by
620411 -        Original Medicare as described in Section 7, ref SDS 0 1F92).
620412 -        The Medicare program pays us to manage health care for people
620413 -        with Medicare who are Senior Advantage Members.  Senior
620414 -        Advantage is not a Medicare supplement policy.  Medicare
620415 -        supplement policies are sometimes called "Medigap" insurance
620416 -        policies (see Section 15 for definition of Medicare Supplement
620417 -        policy).  Kaiser Permanente provides medical care through
620418 -        Medicare-certified Plan Facilities.  In addition, our Plan
620419 -        Providers are in compliance with Medicare credentialing
620420 -        standards.
620422 -  ..
620423 - Restates notice on page i, per above. ref SDS 0 1E91
620425 -  ..
620426 - An issue for legal review apart from whether Kaiser is obligated to
620427 - pay for referral under Section 2, ref SDS 0 WU6M, is whether Kaiser's
620428 - EOC disclaimer of Medigap coverage has been obviated by Kaiser's
620429 - conduct (see issue #14, below, ref SDS 0 MS3K), including public
620430 - notices telling customers to cancel Medigap coverage after signing up
620431 - with Senior Advantage? ref SDS 0 WX6K
620432 -
620433 -            [On 071006 Paula with Kaiser MCRC unit checking for changes
620434 -            in EOC from 2004 to 2007. ref SDS 30 453G
620436 -             ..
620437 -            [On 071018 AARP article reports widespread confusion about
620438 -            differences between Medigap supplemental Medicare policies
620439 -            and HMO insurance coverage due to misrepresentations
620440 -            selling managed care insurance cause beneficiaries to incur
620441 -            significant extra charges. ref SDS 35 CR6T
620443 -  ..
620444 - For approximately, 20 years prior to 2004, Millie was treated by
620445 - Kaiser through employer paid health care.  She turned 65 in 2001, and
620446 - signed up for social security.  She was told social security deducts
620447 - monthly payments for Medicare, and that she should get supplemental
620448 - coverage.  At the time, this was not siginficant, because her full
620449 - coverage at work continued.  In 2004, her employer dropped coverage
620450 - for Kaiser.  Millie was given a choice to leave Kaiser and join
620451 - another health plan fully paid by her employer, or the employer would
620452 - pay additional amounts for Millie to buy insurance, including continue
620453 - with Kaiser.
620455 -  ..
620456 - In 2002 Millie was diagnosed with breast cancer.  Her condition
620457 - worsened considerably in 2004 with diagnosis of rare, aggressive form
620458 - of secondary cancer, reported on 040517, ref SDS 4 Y16I, and at the
620459 - time when the change in insurance occurred.
620461 -  ..
620462 - Millie was told by Kaiser sales representative in 2004 that Senior
620463 - Advantage supplements Medicare, and that she did not need Medigap nor
620464 - nor any further insurance in order to maintain continuity of care for
620465 - the past 30 years, including treatment for cancer begun by Kaiser in
620466 - 2002, and that all of her doctors, medical history, procedures, and
620467 - treatments would remain intact by making a 2nd insurance payment to
620468 - Kaiser.
620470 -             ..
620471 -            [On 071018 AARP article reports widespread confusion about
620472 -            differences between Medigap supplemental Medicare policies
620473 -            and HMO insurance coverage due to misrepresentations
620474 -            selling managed care insurance cause beneficiaries to incur
620475 -            significant extra charges. ref SDS 35 CR6T
620477 -  ..
620478 - As a result, she was never aware of distinctions Kaiser presents on
620479 - page 4, per above, between Senior advantage and supplemental "Medigap"
620480 - coverage. ref SDS 0 1F6L
620482 -  ..
620483 - Kaiser's presentation on page 4 is masked by pressures, emotions, and
620484 - shock of illness that prevent awareness by a panicked cancer patient,
620485 - who is oriented to accept assurances of sales people that payment to
620486 - Medicare, and making a 2nd insurance payment to Kaiser supplements
620487 - Medicare to continue providing essential treatments. (see for example
620488 - the meeting at Kaiser on 040318, when the doctor enrolled her in a
620489 - clinical trial, and all costs were paid by Kaiser without coinsurance.
620490 - ref SDS 3 PU6M)
620492 -  ..
620493 - The fact that none of the professionals at Kaiser nor at UCSF had ever
620494 - heard of coinsurance, nor that patients referred by Kaiser for
620495 - treatment in a clinical trial would be billed extra charges of any
620496 - kind demonstrates Millie was justified in relying on Kaiser's conduct
620497 - in numerous clinical trial referrals to establish that Kaiser paid all
620498 - costs not covered by the trial. (see for example doctor's
620499 - correspondence on 061230, ref SDS 13 3X6K; meeting on 070829 with
620500 - oncology department staff manager, ref SDS 19 EG34; meeting with Member
620501 - Services also on 070829. ref SDS 19 SF52
620503 -  ..
620504 - Reliance on Kaiser's assurance of care for cancer that supplements
620505 - Medicare reflects Kaiser's public position that patients can cancel
620506 - Medigap coverage after signing up for Senior Advantage, reviewed on
620507 - 070917. ref SDS 25 EZ56
620508 -
620509 -            [On 071018 AARP article reports widespread confusion about
620510 -            differences between Medigap supplemental Medicare policies
620511 -            and HMO insurance coverage due to misrepresentations
620512 -            selling managed care insurance cause beneficiaries to incur
620513 -            significant extra charges. ref SDS 35 CR6T
620515 -  ..
620516 - At no time did Kaiser notify Millie that coverage for health care
620517 - would require paying for a 3rd insurance policy when Kaiser prescribes
620518 - treatments by clincial trial, as explained by the doctor on 040318.
620519 - ref SDS 3 PU6M
620521 -  ..
620522 - Kaiser Senior Advantage Page 4 continues and says in part...
620523 -
620524 -    3.  This DF/EOC explains your benefits and Services, what you have
620525 -        to pay, and the rules you must follow to get your care.  Senior
620526 -        Advantage gives you all the Medicare benefits and Services that
620527 -        Medicare covers for everyone (except for hospice care for
620528 -        Members with Medicare Parts A and B and qualifying clinical
620529 -        trials, which are covered directly by Medicare as described in
620530 -        Section 7.
620531 -
620532 -
620533 -
6206 -

SUBJECTS
Medigap Supplemental Coverage Medicare Excluded Kaiser Senior Advant

8103 -
810401 -  ..
810402 - Primary Care Physician Single Point of Contact Case Management
810403 - Insurance Premiums Require Kaiser to Pay for Prescribed Care
810404 - Kaiser Must Prescribe Necessary Treatment for Covered Services
810405 -
810406 -
810407 - Kaiser Senior Advantage Page 9 Section 2 says in part...
810409 -         ..
810410 -        Section 2
810411 -        Getting Care from your primary care Plan Physician
810413 -         ..
810414 -        Your primary care Plan Physician will provide most of your
810415 -        primary care and will help arrange or coordinate other covered
810416 -        Services you get as a Senior Advantage Member (for example,
810417 -        X-rays, laboratory test, theapies, care from Plan Physicians
810418 -        who are specialists, hospital admissions, and follow-up care).
810420 -         ..
810421 -        "Coordinating" your Services includes checking or consulting
810422 -        with other Plan Providers about your care and how it is going.
810423 -        If you need certain types of covered Services, your primary
810424 -        care Plan Physician must prescribe or authorize the Services
810425 -        (for example, some care requires a referral from a Plan
810426 -        Physician for certain types of speciality care).
810428 -  ..
810429 - EOC Section 2 requiring Kaiser to prescribe needed treatment for
810430 - covered Services, like oncology, aligns with traditional medical
810431 - practice that patients rely on the doctor to prescribe care.  This
810432 - complies with HHS Publication No. 00-PO38 issued by the Agency for
810433 - Healthcare Research and Quaity (AHRQ) requiring a single doctor to be
810434 - in charge of case management to insulate fragile patients from delays
810435 - coordinating complex arrangements among multiple health care
810436 - providers, reviewed on 041113. ref SDS 5 JH3Q
810438 -  ..
810439 - In this case, Millie requires "therapy" called out in Section 2,
810440 - ref SDS 0 GN3N, for cancer, commonly called "chemotherapy," which is
810441 - the core component of oncology Services covered by Kaiser insurance
810442 - based on pattern and practice the past 6 years.  Kaiser has used
810443 - clinical trials as part of the doctor's "tool kit" for routine care in
810444 - oncology practice, explained by the doctor on 040318, ref SDS 3 PU6M,
810445 - and cited in the case study on using clinical trials for Millie's care
810446 - shown on 070830. ref SDS 20 LQ5I
810448 -  ..
810449 - On 070917 research found CMS guidance for clinical trial service
810450 - providers to bill Medicare under EOC Section 7, when patients
810451 - self-refer, ref SDS 0 OU84, does not apply to clinical trials
810452 - prescribed by the doctor for treatment of oncology services covered
810453 - under EOC section 2, since Medicare is not billed. ref SDS 25 F28H
810454 - Prescribed treatments are paid from insurance revenues. ref SDS 25
810455 - O45K
810457 -  ..
810458 - Kaiser notified Millie on 020321 that her oncology doctor was assigned
810459 - to be the primary care physician, ref SDS 1 MA3F, for a single point
810460 - of contact providing Millie's treatment in accordance with terms of
810461 - the EOC, similar to a project manager role coordinating work that
810462 - implements contract requirements. ref SDS 1 425M  Millie had no duty
810463 - to read the EOC and tell the doctor what to prescribe.
810465 -             ..
810466 -            [On 071006 Paula with Kaiser MCRC unit checking for changes
810467 -            in EOC from 2004 to 2007. ref SDS 30 453G
810469 -             ..
810470 -            [On 071128 Kaiser Appeals Committee approved payment for
810471 -            Millie's care on referral to UCSF. ref SDS 40 JZ5R
810473 -             ..
810474 -            [On 081112 Kaiser's representative in the Expedited Claims
810475 -            Department advised that Kaiser is lawfully required to
810476 -            implement doctor's orders for patient care. ref SDS 42 PR35
810478 -             ..
810479 -            [On 090521 2006 Doctor Johnson's letter to Millie without
810480 -            copy to medical team refuses to prescribe treatment and
810481 -            tells Millie she can "choose" any treatment she wants,
810482 -            because no treatment is superior for Millie's patient
810483 -            profile, ref SDS 43 9Q9H; Doctor Johnson warns Millie that
810484 -            she needs treatment by the end of the week, which is 12
810485 -            hours because her cancer is progressing rapidly,
810486 -            ref SDS 43 HC8O, and Kaiser tells Millie to call Medicare
810487 -            for a prescription to recover from 8th relapse of cancer.
810488 -            ref SDS 43 9Q9H
810490 -  ..
810491 - Kaiser Senior Advantage Page 9 Section 2 continues...
810492 -
810493 -        In some cases, your primary care Plan Physician will need to
810494 -        get prior authorization (prior approval) as described in the
810495 -        Medical Group authorization procedures for certain referrals in
810496 -        this Section 2.  Since your primary care Plan Physician will
810497 -        provide and coordinate your medical care, you should have all
810498 -        of your past medical records sent to your primary care Plan
810499 -        Physician.  Section 9 tells how we will protect the privacy of
810500 -        your medical records and personal health information.
810502 -  ..
810503 - In this case, on 070105 the primary care physician prescribed
810504 - treatment for breast cancer with cetuximab that was needed by the
810505 - patient, but was not available at Kaiser, ref SDS 14 PK7L, and reported
810506 - have coordinated to arrange for treatment at UCSF, ref SDS 14 PK68, as
810507 - called out in this part of EOC.
810509 -  ..
810510 - Treatment began on 070201, and the next day the primary care physician
810511 - performed required coordination and oversight by meeting with the
810512 - patient, ref SDS 18 0001, and has continued to perform this role.
810514 -  ..
810515 - Kaiser describes "covered Services," ref SDS 0 WS6M, which evidently
810516 - includes oncology care services, since Millie has been getting this
810517 - care since 2002.
810518 -
810519 -
810520 -
810521 -
810522 -
8106 -

SUBJECTS
Clinical Trials Patients Participate Advance Medical Science Doctors

A003 -
A00401 -  ..
A00402 - Kaiser Senior Advantage Page 68 Section 7 says in part...
A00404 -     ..
A00405 -    Section 7
A00406 -    Hospital care, Skilled Nursing Facility care, and other Services
A00407 -
A00408 - Five (5) pages below the main heading, Kaiser says...
A00409 -
A00410 -    1.  Participating in a clinical trial
A00411 -
A00412 -        A "clinical trial" is a way of testing new types of medical
A00413 -        care, like how well a new cancer drug works.  Clinical trials
A00414 -        are one of the final stages of a research process to find
A00415 -        better ways to prevent, diagnose, or treat diseases.  The
A00416 -        trials help doctors and researchers see if a new approach works
A00417 -        and if it is safe.
A00419 -  ..
A00420 - Millie at no time has ever requested treatment in a clinical trial to
A00421 - test drugs, assist research, or for any reason other than for Kaiser
A00422 - to perform its duty of care in section 2, ref SDS 0 WS6M, explained by
A00423 - Kaiser on 040318, ref SDS 3 DG4J, and again in Kaiser's letter on
A00424 - 060809, explaining Kaiser's reputation for providing good care
A00425 - routinely making referrals for needed treatments. ref SDS 10 NT9X
A00426 -
A00427 -        [On 071128 Kaiser Appeals Committee approved payment for
A00428 -        Millie's care on referral to UCSF. ref SDS 40 JZ5R
A00430 -  ..
A00431 - Research on 070917 shows CMS guidance on service providers billing
A00432 - Medicare for patients who self-refer to participate in clinical
A00433 - trials, ref SDS 25 F28H, and does not apply in Millie's case because
A00434 - the doctor prescribed treatment in a clinical trial for covered
A00435 - oncology services under EOC section 2, per above. ref SDS 0 WS6M
A00437 -  ..
A00438 - Millie has been treated in clinical trials only for prescribed care
A00439 - based on the doctor's professional advice that treatment was already
A00440 - proven safe and effective, as shown in the meeting at Kaiser on
A00441 - 040318, ref SDS 3 DG6H, and cited in analysis of CMS section 69.9
A00442 - submitted by UCSF on 070917, ref SDS 25 596Q, and which does not
A00443 - justify charging Millie for coinsurance in this case. ref SDS 25 OH9I
A00444 -
A00445 -            [On 071006 Paula with Kaiser MCRC unit checking for changes
A00446 -            in EOC from 2004 to 2007. ref SDS 30 453G
A00448 -  ..
A00449 - On 041130, Millie resisted treatment with another clinical trial
A00450 - because delay imperiled recovery.  Kaiser persisted in prescribing
A00451 - treatment by clinical trial as the best course of care which Kaiser
A00452 - was duty bound to provide, ref SDS 6 028N, shown by Kaiser's letter on
A00453 - 060809 explaining practice of prescribing treatment on referral to
A00454 - provide the best care. ref SDS 10 NT9X
A00456 -  ..
A00457 - On 041230, Kaiser prescribed conventional treatment only for the
A00458 - purpose of qualifying Millie for another clinical trial. ref SDS 7
A00459 - XQ41  This record of persistently prescribing treatment by referral to
A00460 - clinical trials, which recently on 070921 was reported to save Kaiser
A00461 - money on drug costs, ref SDS 26 QY58, cannot be turned into $10K per
A00462 - year extra charges to the patient, nearly 5 times annual insurance
A00463 - premiums, shown by review of UCSF invoices on 070830. ref SDS 20 W05N
A00465 -  ..
A00466 - Medicare intent to encourage participation in clinical trials in order
A00467 - to reduce costs and save lives of future patients, cannot be misused
A00468 - by managed care enterprises to transfer obligations for reasonable and
A00469 - necessary costs of care from insurance premium coverage to open ended
A00470 - coinsurance out-of-pocket expenses to the patient, especially without
A00471 - notice.  We need statutory authority and analysis that justifies
A00472 - transferring costs to patients under the guise of clinical trial
A00473 - coinsurance, noted in Millie's letter to UCSF on 070904. ref SDS 21
A00474 - 6R3X
A00476 -  ..
A00477 - Kaiser Senior Advantage Page 68 Section 7 continues,...
A00478 -
A00479 -    2.  Medicare pays for routine costs if you take part in a clinical
A00480 -        trial that meets Medicare requirements.  Routine costs include
A00481 -        costs like room and board for a hospital stay that Medicare
A00482 -        would pay for even if you weren't in a trial, and operation to
A00483 -        implant an item that is being tested, and items and Services to
A00484 -        treat side effects and complications arising from the new care.
A00485 -        Generally, Medicare will not cover the costs of experimental
A00486 -        care, such as the drugs or devices being tested in a clinical
A00487 -        trial.
A00489 -         ..
A00490 -    3.  There are certain requirements for Medicare coverage of
A00491 -        clinical trials.  If you participate as a patient in a clinical
A00492 -        trial that meets Medicare requiremetns, Original Medicare (and
A00493 -        not Senior Advantage) pays for the clinical trial doctors and
A00494 -        other providers for the covered services you receive that are
A00495 -        related to the clinical trial.  When you are in a clinical
A00496 -        trial, you may stay enrolled in Senior Advantage and continue
A00497 -        to get the rest of your care that is unrelated to the clinical
A00498 -        trial through Senior Advantage.
A00499 -
A00500 -
A00501 -
A006 -

SUBJECTS
Coinsurance 20% Clinical Trials Patient Responsibility Medicare Pays

AL03 -
AL0401 -  ..
AL0402 - Medicare Pays Lab Costs for Clinical Trials
AL0403 - Laboratory Blood Tests Paid by Medicare No Coinsurance
AL0404 - Coinsurance 20% Patient Pays Clinical Trials Advance Medical Science
AL0405 - Clinical Trial Service Provider Must Explain Charges Prior to Services
AL0406 -
AL0407 -
AL0408 -    4.  You will have to pay Original Medicare coinsurance for the
AL0409 -        Services you receive when participating in a qualifying
AL0410 -        clinical trial.  You do not have to pay the Original Medicare
AL0411 -        Part A or Part B deductibles, because you are enrolled in
AL0412 -        Senior Advantage.  For instance, you will be responsible for
AL0413 -        Part B coinsurance, generally 20% of the Medicare approved
AL0414 -        amount for most doctor Services and most other outpatient
AL0415 -        Services.  However, there is no coinsurance for Medicare
AL0416 -        covered clinical laboratory Services related to the clinical
AL0417 -        trial.
AL0419 -  ..
AL0420 - This language Section 7 for EOC dated 070101 that patients "have to
AL0421 - pay coinsurance" is clarified by Kaiser's documentation received from
AL0422 - Member Services on 070829 saying coinsurance "may apply" to clinical
AL0423 - trials, ref SDS 19 SF4I, when patients self-refer, per below,
AL0424 - ref SDS 0 1G4O, since EOC Section 2 requires Kaiser to pay costs of
AL0425 - prescribed treatment, which Kaiser must perform for covered oncology
AL0426 - services, per above? ref SDS 0 WS6M
AL0428 -  ..
AL0429 - Section 7 of Kaiser's EOC saying patients are liable for 20%
AL0430 - coinsurance aligns somewhat with authority received from UCSF on
AL0431 - 070917 that cites CMS Medicare Claims Processing Manual Publication
AL0432 - 100-04, Chapter 32 Section 69.9. ref SDS 25 4P4I  Review at that time
AL0433 - indicated Millie is not liable for costs of implementing this part of
AL0434 - Medicare regulations. ref SDS 25 OH9I
AL0436 -             ..
AL0437 -            [On 071006 Paula with Kaiser MCRC unit checking for changes
AL0438 -            in EOC from 2004 to 2007. ref SDS 30 453G
AL0440 -  ..
AL0441 - Kaiser's documents received from Member Services on 070829 say that
AL0442 - clinical trial service provider must explain charges in advance of
AL0443 - starting services. ref SDS 19 SF52
AL0445 -  ..
AL0446 - Research on 070917 supports Kaiser's requirements for clinical trial
AL0447 - provider to explain charges. ref SDS 25 416K  This conflicts with the
AL0448 - record on 070105; Kaiser failed to disclose charges to the patient.
AL0449 - ref SDS 14 PK68  Similarly, on 070130 UCSF failed to disclose extra
AL0450 - costs for treatment in the clinical trial. ref SDS 16 LY9H
AL0451 - Additionally, on 070906 Doctor Rugo disclosed having no knowledge of
AL0452 - billing charges to patients. ref SDS 22 UK5M  The next day on 070907,
AL0453 - the primary care physician at Kaiser also has no knowledge of billing
AL0454 - charges for clinical trials. ref SDS 24 XH5H
AL0455 -
AL0456 -            [On 071011 Millie requests UCSF explain confusing billings,
AL0457 -            citing Doctor Rugo's comment that requirements are "very
AL0458 -            muddy." ref SDS 33 K65V
AL0460 -             ..
AL0461 -            [On 071026 UCSF responds, ref SDS 36 K49J, and demands
AL0462 -            payment of its claim against Millie within 1 week.
AL0463 -            ref SDS 36 SU5V
AL0465 -             ..
AL0466 -            [On 071027 patient requests meeting so UCSF can present
AL0467 -            claim, and explain charges. ref SDS 37 CG6H
AL0469 -             ..
AL0470 -            [On 071029 UCSF refuses to meet; claims suffering from
AL0471 -            delay by patient "stringing out payments. ref SDS 38 6N6K
AL0473 -             ..
AL0474 -            [On 071128 Kaiser Appeals Committee approved payment for
AL0475 -            Millie's care on referral to UCSF. ref SDS 40 JZ5R
AL0477 -  ..
AL0478 - Senior Advantage requirement for patient payment of 20% coinsurance to
AL0479 - participate in clinical trials for advancing medical insurance under
AL0480 - section 7, does not relieve Kaiser from responsibility to prescribe
AL0481 - and pay with insurance premium revenue costs of needed care under
AL0482 - section 2, since in this case chemotherapy is an oncology covered
AL0483 - Service. ref SDS 0 WT37
AL0485 -  ..
AL0486 - EOC section 7 aligns with internal memo received from Kaiser on 070906
AL0487 - telling doctors that Kaiser cannot prescribe treatment through
AL0488 - clinical trials for Senior Advantage beneficiaries, ref SDS 23 WC5P,
AL0489 - and conflicts with Kaiser's practice to use clinical trials to expand
AL0490 - treatment options for patients. ref SDS 23 HD3K
AL0492 -  ..
AL0493 - Kaiser's notice that Senior Advantage requires payment of coinsurance
AL0494 - for clinical insurance was at all times masked by Kaiser's conduct
AL0495 - repeatedly referring Millie for treatament in clinical trials for
AL0496 - routine oncology practice, and never charging for coinsurance, as
AL0497 - shown in case study on 070830. ref SDS 20 LQ5I  Kaiser's conduct
AL0498 - obviated any requirement for Millie to have taken time away from
AL0499 - health care activities to study Kaiser documentation.
AL0501 -  ..
AL0502 - Kaiser's guidance indicating Medicare pays the full cost of laboratory
AL0503 - services for blood tests, aligns with documentation from Kaiser Member
AL0504 - Services received on 070829. ref SDS 19 695L  As a result, there is no
AL0505 - coinsurance for laboratory services required for standard of care in
AL0506 - clinical trials.  This representation seems to conflict with Bob
AL0507 - Schwartz's report on 070830 that Kaiser billed the patient for blood
AL0508 - tests. ref SDS 20 T149  The sample UCSF invoice approved by Kaiser has
AL0509 - extensive charges for blood test work performed by laboratory
AL0510 - Services. ref SDS 20 4P8K
AL0512 -  ..
AL0513 - May raise questions of billing irregularities, shown in issue #13
AL0514 - below. ref SDS 0 WW4O
AL0515 -
AL0516 -            [On 071010 UCSF letter seems to say Millie is not charged
AL0517 -            coinsurance on blood tests; refusal to submit details
AL0518 -            showing how charges are calculated, raises questions of
AL0519 -            billing irregularities. ref SDS 32 T64J
AL0521 -  ..
AL0522 - Kaiser Senior Advantage Page 68 Section 7 continues,...
AL0523 -
AL0524 -    5.  The Medicare program has written a booklet that includes
AL0525 -        information on Original Medicare coinsurance rules, called
AL0526 -        "Medicare & You."  To get a free copy, please call 1 800 633
AL0527 -        4227 or visit http://www.medicare.gov on the web.  Also the
AL0528 -        Medicare program has written a booklet aobut Medicare and
AL0529 -        Clinical Trials."  To obtain a free copy, please call 1 800 633
AL0530 -        4227 or visit http://www.medicare.gov on the web.  Section 1
AL0531 -        tells more about how to contact the Medicare program and about
AL0532 -        Medicare's website.
AL0533 -
AL0535 -         ..
AL0536 -        Self-referral for Clinical Trials Without Doctor Authorization
AL0537 -
AL0538 -
AL0539 -    6.  You should continue to come to Plan Providers for all covered
AL0540 -        Services that are not part of the clinical trial.  Original
AL0541 -        Medicare does not require that you get a referral from a Plan
AL0542 -        Physician to join a qualifying clinical trial.  However, you
AL0543 -        should tell us before you join a clinical trial outside of
AL0544 -        Kaiesr Permanente so we can keep track of your Services.
AL0546 -  ..
AL0547 - Kaiser's policy on clinical trials for patients volunteering to
AL0548 - support medical research, per above, ref SDS 0 1F92, calls for
AL0549 - coinsurance when patients "self-refer" for treatment in a clinical
AL0550 - trial. ref SDS 23 WC6S  Review at that time shows Kaiser made the
AL0551 - referral in order to provide prescribed treatment, ref SDS 23 OQ6K,
AL0552 - and citing case study on 070830. ref SDS 20 LQ5I
AL0553 -
AL0554 -
AL0555 -
AL06 -

SUBJECTS
Clinical Trials Dispute Coinsurance 20% 16 Issues Presented Kaiser S

B803 -
B80401 -  ..
B80402 - 16 Issues presented in Kaiser's Referral Dispute with UCSF
B80403 - Kaiser Must Prescribe Needed Care for Oncology Services EOC 2
B80404 - Patient Relied on Doctor Point of Contact with Kaiser EOC Sec 2
B80405 -
B80406 - This case presents at least 16 issues involving patient health,
B80407 - Medicare law and regulation, CMS contract management, medical
B80408 - practice, ethics and standards for oncology care using clinical
B80409 - trials, cost containment, and billing procedures.  At stake is whether
B80410 - Kaiser can transfer 100% of cost for patient care to others simply by
B80411 - prescribing treatment in clinical trials?
B80413 -  ..
B80414 - Goals for resolution of dispute are listed on 070830. ref SDS 20 T94H
B80415 -
B80416 -            [On 071002 letter to CMS asks if Medicare law prohibits
B80417 -            Kaiser (HMO) from paying for prescribed treatment in
B80418 -            clinical trials? ref SDS 27 OY4Q
B80420 -             ..
B80421 -            [On 071003 James Mayhew requested submission of issues for
B80422 -            public policy review at CMS. ref SDS 28 I34O
B80424 -             ..
B80425 -            [On 071003 Jullin Kwok manages Medicare contract with
B80426 -            Kaiser for Senior Advantage, and noted complexity of
B80427 -            Millie's case. ref SDS 28 BZ40
B80429 -             ..
B80430 -            [On 071006 Paula McPhail called and advised Kaiser received
B80431 -            50 pages of documents via fax from CMS, and converted this
B80432 -            into an appeal on Millie's behalf for Kaiser to pay for
B80433 -            prescribed treatments at UCSF. ref SDS 30 Z87L
B80435 -             ..
B80436 -            [On 071009 Jullin Kwok called and advised the letter dated
B80437 -            071002 to CMS along with 50 pages of citations was printed
B80438 -            and submitted for research; does not mention faxing 50
B80439 -            pages to Kaiser. ref SDS 31 EX5J
B80441 -             ..
B80442 -            [On 071128 Kaiser Appeals Committee approved payment for
B80443 -            Millie's care on referral to UCSF. ref SDS 40 JZ5R
B80445 -         ..
B80446 -    1.  What is Kaiser's duty of care; can the patient rely on the
B80447 -        doctor to prescribe treatment?
B80449 -         ..
B80450 -        Kaiser Senior Advantage EOC Section 2
B80451 -        Getting care from your primary care Plan Physician
B80452 -
B80453 -        ...says in part...
B80454 -
B80455 -            "If you need certain types of covered Services, your
B80456 -            primary care Plan Physician must prescribe or authorize the
B80457 -            Services (for example, some care requires a referral from a
B80458 -            Plan Physician for certain types of speciality care)."
B80459 -            ref SDS 0 WT37
B80461 -         ..
B80462 -        In this case, on 070105 the doctor determined Millie needed
B80463 -        oncology care with cetuximab. ref SDS 14 PK7L  Kaiser was faced
B80464 -        with a choice of buying the drug and administering treatment at
B80465 -        Kaiser (which would be expensive for Kaiser, reported recently
B80466 -        on 070921, ref SDS 26 QY58), or making referral to UCSF where
B80467 -        the drug would be paid by a clinical trial.  What was done?
B80468 -        The doctor prescribed the cost effective solution of treatment
B80469 -        at UCSF.  The doctor performed Kaiser's duty of care by
B80470 -        coordinating and making arrangements with UCSF so that Millie
B80471 -        was treated, as called out in Kaiser's EOC section 2,
B80472 -        ref SDS 0 WS6M, shown by Kaiser correspondence with UCSF on
B80473 -        061230, ref SDS 13 3X6K, and confirmed by the doctor's letter
B80474 -        to Millie on 070119 stating auhorization was submitted for
B80475 -        treatment on referral to the clinical trial at UCSF.
B80476 -        ref SDS 15 4R4M
B80478 -             ..
B80479 -            [On 071004 Medicare policy questions submitted to
B80480 -            James Mayhew at CMS for review. ref SDS 29 P74W
B80482 -         ..
B80483 -        The doctor's decision on 070105 has resulted in significantly
B80484 -        improved health for Millie, and significant savings for Kaiser
B80485 -        by avoiding the cost of the drug, and, also, the cost of
B80486 -        laboratory blood tests, which Kaiser would otherwise pay with
B80487 -        insurance preimum revenues but for treatment in the clinical
B80488 -        trial.  The doctor's decision has been a stunning success.
B80490 -         ..
B80491 -        In performing Kaiser's duties under EOC Section 2, can the
B80492 -        patient rely on the doctor as the single point of contact to
B80493 -        provide necessary research and coordination to arrange for
B80494 -        treatments according to requirements of the EOC, ref SDS 0
B80495 -        WS6M, including payments for coinsurance, if applicable, under
B80496 -        section 7? ref SDS 0 OU8P  In the absence of notice by Kaiser
B80497 -        of extra costs, as occurred here, can the patient rely on past
B80498 -        pattern and practice of Kaiser prescribing clinical trials for
B80499 -        oncology treatment without extra cost as notice of continuing
B80500 -        practice, explained by the doctor at Kaiser on 040318,
B80501 -        ref SDS 3 PU6M, and further shown by case study on 070830 that
B80502 -        Kaiser has consistently relied on referrals and clinical trials
B80503 -        for performing EOC covered services for oncology. ref SDS 20
B80504 -        LQ5I
B80505 -
B80506 -           [On 071128 Kaiser Appeals Committee approved payment for
B80507 -           Millie's care on referral to UCSF. ref SDS 40 JZ5R
B80509 -         ..
B80510 -        Or, must the patient review the insurance policy EOC to assess
B80511 -        every doctor order for added charges, and must Kaiser provide
B80512 -        additional people in the examination room to guide
B80513 -        determinination of costs and benefits balancing obtuse
B80514 -        provisions in lengthy insurance contracts, and in order to
B80515 -        prescribe treatment for routine care?  If the patient cannot
B80516 -        rely on good faith, expertise, and experience of the doctor, as
B80517 -        the single point of contact, called out in section 2,
B80518 -        ref SDS 0 WS6M, how can medical practice survive with multiple
B80519 -        conflicting instructions?
B80521 -         ..
B80522 -    2.  Double dipping.. save on drug costs and avoid other costs...
B80523 -
B80524 -        Section 7 in Kaiser's EOC says Kaiser avoids costs of drugs,
B80525 -        because the clinical trial sponsor pays for chemotherpay drugs,
B80526 -        ref SDS 0 1F4K; it also appears Medicare pays the full cost of
B80527 -        laboratory services (blood tests) for clinical trials.
B80528 -        ref SDS 0 1F67
B80530 -         ..
B80531 -        Having saved the cost of drugs and labs in this case, can
B80532 -        Kaiser transfer responsibility for payment of all other costs
B80533 -        for prescribed oncology care to others:  roughly 80% to
B80534 -        Medicare and 20% to the patient through the simple expedient of
B80535 -        prescribing treatment in a clinical trial?  What benefit is the
B80536 -        patient deriving in exchange for payment of insurance premiums,
B80537 -        if Kaiser avoids all costs of care for covered oncology
B80538 -        Services under section 2, ref SDS 0 WS6M, merely by prescribing
B80539 -        treatment in a clinical trial under section 7? ref SDS 0 OU84
B80540 -
B80541 -           [On 071128 Kaiser Appeals Committee approved payment for
B80542 -           Millie's care on referral to UCSF. ref SDS 40 JZ5R
B80544 -         ..
B80545 -    3.  Can Kaiser avoid its duty to prescribe necessary care for
B80546 -        covered oncology Services specified in section 2, ref SDS 0
B80547 -        WS6M, on grounds that oncology practice requires treatment in
B80548 -        clinical trials, noted by the doctor on 040318, ref SDS 3 PU6M,
B80549 -        but participation in clinical trials are not covered Services,
B80550 -        when patients self-refer to advance medical science, set out in
B80551 -        section 7? ref SDS 0 OU84
B80553 -         ..
B80554 -    4.  Can Kaiser avoid its duty to prescribe needed care for oncology
B80555 -        services under Section 2 of the EOC, ref SDS 0 WS6M, in light
B80556 -        of 2nd opinions from accredited cancer center specialists (see
B80557 -        Doctor Benz UCSF opinion received from Kaiser on 060929,
B80558 -        ref SDS 11 UI9K) recommending such treatment, which the doctor
B80559 -        determines is essential to sustain the health of the patient,
B80560 -        who necessarily is alwyas running out of limited treatments for
B80561 -        cancer available to front-line doctors at Kaiser, noted by
B80562 -        Millie's doctor on 040318, ref SDS 3 DG4J, and again during the
B80563 -        meeting on 041130? ref SDS 6 028N (see also discussion on
B80564 -        limited drugs at Kaiser, ref SDS 6 763L)
B80566 -         ..
B80567 -    5.  Can Kaiser avoid its duty to pay costs of covered Services for
B80568 -        oncology care, set out in Section 2 of the EOC, ref SDS 0 WS6M,
B80569 -        by prescribing treatment in a clinical trial on grounds that an
B80570 -        EOC implements Medicare policy to empower patients to
B80571 -        "self-refer" in order to advance medical scieince? ref SDS 0
B80572 -        OU84  What is Kaiser's legal duty to prescribe care?
B80574 -         ..
B80575 -    6.  Can patients disregard Kaiser's prescribed treatment under
B80576 -        Section 2, ref SDS 0 WS6M, to seek treatment from a service
B80577 -        provider outside Kaiser's Health Plan in a clinical trial for
B80578 -        the purpose of advancing medical science, under section 7,
B80579 -        ref SDS 0 OU84, and in that case Kaiser avoids costs and
B80580 -        responsiblity of self-referral by the patient (see review of
B80581 -        Kaiser's "self-referal" theory on 070830, ref SDS 20 T259),
B80582 -        which is not what occurred in this case, and is not the intent
B80583 -        of the patient, as further shown in the record on 070830?
B80584 -        ref SDS 20 QX5K
B80586 -         ..
B80587 -    7.  Can Kasiser implement Medicare policy to encourage
B80588 -        participation in clinical trials by paying for essential
B80589 -        prescribed treatment under section 2, and charging the patient
B80590 -        20% coinsurance only when the patient self-refers to advance
B80591 -        medical science under section 7? ref SDS 0 OU84
B80593 -         ..
B80594 -    8.  Kaiser cost transfer scheme "cut loose" the patient to fend for
B80595 -        herself conflicts with duty of care and accountability for
B80596 -        performance?
B80598 -         ..
B80599 -        Can Kaiser benefit from public policy (Medicare) to encourage
B80600 -        participation in clincial trials for advancing medical science,
B80601 -        shown in Kaiser's documentation reviewed on 070829, ref SDS 19
B80602 -        SF4I, and also stated in EOC section 7, ref SDS 0 OU84, by
B80603 -        cutting the patient loose to fend for herself in order to avoid
B80604 -        all costs of care from diverting payment for 80% to Medicare,
B80605 -        and converting a patient's legal right to "self-refer" paying
B80606 -        20% of costs, into a cost transfer scheme that shields Kaiser
B80607 -        from its duty to prescribe needed care and retain responsbility
B80608 -        for covered oncology services and to pay for that care with
B80609 -        revenues from insurance premiums, and can Kaiser additionally
B80610 -        be absolved from responsibility and accountability for standard
B80611 -        of care required by EOC section 2? ref SDS 0 WS6M (see prior
B80612 -        analysis on 070830, reporting patient intent for Kaiser to
B80613 -        retain responsibility for patient care. ref SDS 20 QX5K)
B80614 -
B80615 -              [On 071018 Doctor Rugo reported understandings that
B80616 -              Millie was "cut loose" by Kaiser to fend for herself
B80617 -              working with UCSF for treatment prescribed by Kaiser.
B80618 -              ref SDS 34 W23I
B80620 -         ..
B80621 -    9.  Did Kaiser change its EOC policy in section 7 published at the
B80622 -        beginning of 2007 and stating that patients "have to pay" for
B80623 -        coinsurance in the amount generally of 20%, ref SDS 0 1F67,
B80624 -        when Kaiser's public documents advertise that patients "may
B80625 -        have to pay" for coinsurance to self-refer for treatment that
B80626 -        advances medical science, reported on 070829 by Kaiser Member
B80627 -        Services? ref SDS 19 SF4I  Should not Kaiser retain
B80628 -        responsibility for costs of prescribed and necessary treatment
B80629 -        for covered oncology services, under Section 2? ref SDS 0 WS6M
B80631 -         ..
B80632 -   10.  If Kaiser's clinical trial EOC provisions prevent Kaiser from
B80633 -        prescribing needed treatment, did Kaiser's conduct in this case
B80634 -        modify the EOC agreement between Kaiser and the patient to
B80635 -        require that Kaiser pay for costs of clinical trial at UCSF,
B80636 -        as had been done previously...
B80637 -
B80638 -            a.  Pattern and practice for 6 years (mostly in 2004)
B80639 -                Kaiser prescribing and insisting on treatment in
B80640 -                clinical trials as essential component of professional
B80641 -                oncology practice and paying for all costs, without
B80642 -                charging the patient coinsurance, shown by case study
B80643 -                on 070830? ref SDS 20 LQ5I
B80645 -                 ..
B80646 -            b.  Kaiser coordinated and arranged for treatment in this
B80647 -                case with UCSF and agreed to pay any costs not covered
B80648 -                by clinical trial, reported in Kaiser correspondence on
B80649 -                061230? ref SDS 13 3X6K
B80651 -                 ..
B80652 -            c.  Kaiser never notified the patient of an interpretation
B80653 -                that Kaiser's referral by the doctor for treatment at
B80654 -                UCSF in a clinical trial was actually a "self-referral"
B80655 -                under Section 7 that required the patient to pay 20% of
B80656 -                costs for coinsurance, necessary to overcome logical
B80657 -                inference from Kaiser's prior conduct, and express
B80658 -                represention in this particular case that Kaiser paid
B80659 -                all costs not covered by the clinical trial.  Kaiser's
B80660 -                duty under EOC Section 2 required providing a single
B80661 -                point of contact for coordinating and arranging for
B80662 -                patient care. ref SDS 0 WS6M  Kaiser never told the
B80663 -                patient the order of magnituge of coinsurance would be
B80664 -                $10K above annual insurance premiums, and 56% of
B80665 -                clinical trial costs approved by medicare, shown by
B80666 -                UCSF charges presented during a meeting at UCSF on
B80667 -                070830. ref SDS 20 QW8M
B80669 -         ..
B80670 -   11.  Notice requirements were not met by Kaiser.
B80671 -
B80672 -        If Kaiser's clinical trial EOC provisions prevent Kaiser from
B80673 -        prescribing needed treatment, and require the patient to pay
B80674 -        20% coinsurance covering costs for prescribed treatment in
B80675 -        addition to insurance premiums, did Kaiser meet its duty of
B80676 -        notice performing case management specified in EOC section 2,
B80677 -        ref SDS 0 WS6M, by failing to present to the patient language
B80678 -        in section 7 on page 68, and in light of Kaiser's
B80679 -        representations to the customer in 2004 at the time of signing
B80680 -        up for Kaiser Senior Advantage that this would continue care
B80681 -        for a continuing condition of cancer, ref SDS 0 H75F, and
B80682 -        further telling the patient that Kaiser would pay any costs not
B80683 -        covered by the clinical trial, reported in Kaiser
B80684 -        correspondence on 061230? ref SDS 13 3X6K
B80686 -         ..
B80687 -        Did the patient have a duty to take notice of (i.e., read and
B80688 -        understand) Kaiser's EOC, when Kaiser's conduct at all times
B80689 -        showed Kaiser paid all costs of referrals and other costs of
B80690 -        care for continuing condition?
B80692 -         ..
B80693 -   12.  Age discrimination - does Kaiser policy to pay for referrals
B80694 -        that provide prescribed treatment needed by customers under age
B80695 -        65 discriminate by withholding the same prescribed treatment
B80696 -        needed for patients 65 and older?  On 030606 Millie asked
B80697 -        Kaiser if treatment was being withheld in order to favor
B80698 -        younger patients?  At that time, the doctor assured that
B80699 -        withholding needed treatment on the basis of age is against the
B80700 -        law? ref SDS 2 XR7I  Can Kaiser circumvent policy against age
B80701 -        discrimination by forcing older patients on fixed retirement
B80702 -        incomes to pay 20% higher prices for cancer care as a
B80703 -        "self-referral" to advance medical science, under section 7,
B80704 -        ref SDS 0 OU84, when Kaiser does not charge the same 20%
B80705 -        premium to younger patients with active incomes, when both
B80706 -        classes of patients require treatment for covered oncology
B80707 -        services?
B80709 -         ..
B80710 -   13.  Administration - compounding emotional, medical trauma.
B80711 -
B80712 -        Medical care, management, coordination, and billings are
B80713 -        complex and so stressful for medical professionals, shown by
B80714 -        example of UCSF invoice on 070830. ref SDS 20 4P8K  Millie's
B80715 -        case is especially complicated, noted by case study on 061020.
B80716 -        ref SDS 12 T25H  Cancer patients are necessarily handicapped
B80717 -        and so dependent on the doctor to simplify complexity to a
B80718 -        level that enables knowing judgements and decisions, noted by
B80719 -        Millie's doctor at Kaiser on 070921. ref SDS 26 CU58
B80721 -         ..
B80722 -        On 070921 the primary care physician reported Millie suffering
B80723 -        stress and trauma from dealing with unexpected medical bills
B80724 -        for clinical trial prescribed and arranged by Kaiser.
B80725 -        ref SDS 26 QY9V  Kaiser's failure to perform arrangements made
B80726 -        with UCSF on 061230, as called out in section 2 of the EOC,
B80727 -        ref SDS 0 WS6M, to pay any costs not covered by the clinical
B80728 -        trial, ref SDS 13 3X6K, "cut loose" a 72 year old enfeebled
B80729 -        cancer patient to assume the duties of the primary care
B80730 -        physician and Kaiser's team of medical financial experts to
B80731 -        manage treatment and billing activities at UCSF, required by
B80732 -        EOC Section 2. ref SDS 0 WS6M
B80734 -               ..
B80735 -              [On 071018 UCSF reports Kaiser advised UCSF in January
B80736 -              that the patient was "cut loose" to fend for herself
B80737 -              through self-referral clinical trial treatment which
B80738 -              Kaiser had prescribed. ref SDS 34 W23I
B80740 -         ..
B80741 -        Kaiser's failure to perform required support resulted in Millie
B80742 -        receiving over 100 pages of invoices with thousands of charges
B80743 -        that require review and audit for compliance with terms and
B80744 -        conditions negotiated by Kaiser, and in which the patient had
B80745 -        no hand, and no inkling of obligation for 6 months.  Initially,
B80746 -        patients must withstand trauma from the shock of getting
B80747 -        endless billings that demand payment for charges that cannot be
B80748 -        verified, illustrated by UCSF's invoice reviewed at UCSF during
B80749 -        a meeting on 070830, ref SDS 20 4P8K, and yet face devestating
B80750 -        threat of being denied essential treatment, all in the wake of
B80751 -        experience never having received even a single invoice from
B80752 -        Kaiser for 6 years of prior treatment.  This presents an easy,
B80753 -        inviting target for opportunists to overcharge, even if by
B80754 -        inadvertance, reported on 070830. ref SDS 20 RV6F
B80755 -
B80756 -            [On 071031 Millie receives notice dated 071026 UCSF plans
B80757 -            referral to collection agency for payment of $202.65 on
B80758 -            Kaiser referral account 12493370, ref SDS 39 KK4I, revised
B80759 -            070830, ref SDS 20 4P8K, and revised again on 070917,
B80760 -            ref SDS 25 MK4H; no indication of UCSF collection efforts
B80761 -            against Kaiser; separate notice dated 071027 and also
B80762 -            received 071031 UCSF says Millie's treatment for cancer
B80763 -            ordered by Kaiser will be terminated if UCSF does not
B80764 -            receive payment of $202.65. ref SDS 39 KM8J
B80766 -         ..
B80767 -        Cutting the patient loose from Kaiser payment support forces
B80768 -        patients to learn complex accounting practices in order to
B80769 -        understand delphic claims which even the claimant (here UCSF)
B80770 -        cannot explain, reported on 070830. ref SDS 20 WU5N  The
B80771 -        patient must futher become an expert in Medicare law for
B80772 -        determining correct application of entitlement and calculation
B80773 -        of quantum, illustrated by the record on 070917. ref SDS 25
B80774 -        596Q  Does Kaiser really intend for senior citizens fighting to
B80775 -        survive and remain productive to perform medical coordination
B80776 -        duties specified in section 2 of the EOC for the primary care
B80777 -        physician, ref SDS 0 WS6M, backed up by legions of trained and
B80778 -        experienced legal and financial personnel?  Shouldn't Kaiser
B80779 -        and UCSF staff be negotiating sensible, efficient billing
B80780 -        processes for routine payments and audits rather than place
B80781 -        this Hurculean task on the patient?  If Kaiser pays for costs
B80782 -        as originally promised and required by EOC section 2 (see
B80783 -        above, ref SDS 0 WS6M), and as performed on prior trials (see
B80784 -        case study on 070830, ref SDS 20 LQ5I), and as provided for
B80785 -        younger patients, would not Kaiser and UCSF professionals
B80786 -        working with Medicare bring order and efficiency to the billing
B80787 -        process?  Would this not reduce overbilling enfeebled,
B80788 -        frightened senior citizen as inviting targets of opportunity
B80789 -        for "financial engineering" to "harvest" extra revenues,
B80790 -        illustrated by the record on 070917? ref SDS 25 595P
B80791 -
B80792 -            [On 071006 billing irregularities arising from complex
B80793 -            calculation procedures, ref SDS 30 454M, cause duplication
B80794 -            and overcharging concerns that conflict with public policy
B80795 -            to simplify procedures and reduce emotional and financial
B80796 -            costs of care for seniors. ref SDS 30 PRWW
B80798 -             ..
B80799 -            [On 071010 Millie requests explanation of UCSF evident
B80800 -            duplicate charges for medical services, ref SDS 32 HZ6S,
B80801 -            reported on 071006. ref SDS 30 PRWW
B80803 -             ..
B80804 -            [On 071010 UCSF refuses to explain charges in complex
B80805 -            billings; refers patient to 3rd part. ref SDS 32 OH7R
B80807 -             ..
B80808 -            [On 071010 UCSF letter seems to say Millie is not charged
B80809 -            coinsurance on blood tests; refusal to submit details
B80810 -            showing how charges are calculated, raises questions of
B80811 -            billing irregularities. ref SDS 32 T64J
B80813 -             ..
B80814 -            [On 071018 Doctor Rugo reports understandings from Kaiser
B80815 -            in January that Millie was "cut loose" to fend for herself
B80816 -            getting treatment at UCSF. ref SDS 34 W23I
B80818 -         ..
B80819 -   14.  Kaiser told Millie she did not need additional insurance.
B80820 -
B80821 -        If Kaiser's view is correct that Millie "self-referred,"
B80822 -        despite the fact that Kaiser made all referral arrangements,
B80823 -        then did Kaiser's assurance that signing up for Kaiser Senior
B80824 -        Advantage would continue prior benefits for treating continuing
B80825 -        condition defeat any provisions that the EOC is not sufficient
B80826 -        to maintain her prior coverage that paid for treatment of a
B80827 -        continuing condition in clinical trials without charging 20%
B80828 -        for coinsurance, and did this reasonably mislead and prevent
B80829 -        Millie from obtaining additional Medigap coverage which Kaiser
B80830 -        maintains is not part of Senior Advantage, per section 1,
B80831 -        ref SDS 0 1F6L, and which Medicare law intends to encourage
B80832 -        patients to purchase as supplemental coverage to pay for
B80833 -        coinsurance charges?
B80834 -
B80835 -           [On 071006 Millie received billings from UCSF in the amount
B80836 -           of $15K - $20K per year for coinsurance. ref SDS 30 PRWW
B80838 -            ..
B80839 -           [On 071018 AARP article reports widespread confusion about
B80840 -           differences between Medigap supplemental Medicare policies
B80841 -           and HMO insurance coverage due to misrepresentations
B80842 -           selling managed care insurance cause beneficiaries to incur
B80843 -           significant extra charges. ref SDS 35 CR6T
B80845 -            ..
B80846 -           [On 071128 Kaiser Appeals Committee approved payment for
B80847 -           Millie's care on referral to UCSF. ref SDS 40 JZ5R
B80849 -         ..
B80850 -   15.  Do Kaiser's public statments that customers who purchase Kaiser
B80851 -        Senior Advantage may consider cancelling their Medigap policy
B80852 -        coverage demonstrate that Kaiser either recognizes
B80853 -        responsibility for Medigap scope, or misled customers in order
B80854 -        to increase sales by conveying promise of coverage that is
B80855 -        expressly denied in the EOC, reported on 070917? ref SDS 25
B80856 -        EZ56
B80857 -
B80858 -           [On 071018 AARP article reports widespread confusion about
B80859 -           differences between Medigap supplemental Medicare policies
B80860 -           and HMO insurance coverage due to misrepresentations
B80861 -           selling managed care insurance cause beneficiaries to incur
B80862 -           significant extra charges. ref SDS 35 CR6T
B80864 -         ..
B80865 -   16.  If Kaiser misdiagnosed and delayed treatment during 2003 due to
B80866 -        errors and omissions that allowed cancer to reach sustaining
B80867 -        strength (see case study on 040517, ref SDS 4 S66O), can Kaiser
B80868 -        under Medicare law pay for continuing treatment through
B80869 -        clinical trials for routine oncology practice, as Kaiser
B80870 -        explained on 040318, ref SDS 3 PU6M, and for the purpose of
B80871 -        mitigating damages?  If Kaiser then further delayed treatment
B80872 -        at the end of 2004 after removing the patient from treatment in
B80873 -        a clinical trial that caused pulmonary embolism, and such delay
B80874 -        in resuming treatment allowed cancer to spread beyond a point
B80875 -        that could be treated by surgery, reported by the surgeon on
B80876 -        050104, ref SDS 8 IS5N, and particularly explained further at
B80877 -        that time, ref SDS 8 UM6I, while Kaiser searched, against
B80878 -        patient request, for further clinical trial treatment to
B80879 -        prescribe, which at that time saved Kaiser money by reducing
B80880 -        the cost of drugs, reported on 041230, ref SDS 7 2V85, with the
B80881 -        result that surgery on 051021 failed on 060711, requiring
B80882 -        further systemic treatment with chemotherapy to the present
B80883 -        day, ref SDS 9 QK7H, can Kaiser now contort it's own conduct to
B80884 -        prescribe clinical trial treatments to mitigate damages from
B80885 -        errors and omissions in medical practice into patient
B80886 -        "self-referral" for the purpose of avoiding accountability for
B80887 -        all costs of care?  Does Medicare law prevent Kaiser from
B80888 -        fixing their mistake by paying for needed treatment on clinical
B80889 -        trial at this time?  Did Kaiser breach its duty of care by
B80890 -        "cutting the patient loose" to fend for herself and without
B80891 -        notice rather than provide continuing care of a continuing
B80892 -        condition, which was compounded by Kaiser searching for
B80893 -        clinical trials to meet obligations under section 2 of the EOC?
B80894 -        ref SDS 0 WS6M
B80896 -               ..
B80897 -              [On 071018 UCSF reports Kaiser advised in January that
B80898 -              the patient was "cut loose" to fend for herself through
B80899 -              self-referral process for treatment Kaiser prescribed in
B80900 -              clinical trial. ref SDS 34 W23I
B80902 -               ..
B80903 -              [On 071128 Kaiser Appeals Committee approved payment for
B80904 -              Millie's care on referral to UCSF. ref SDS 40 JZ5R
B80905 -
B80906 -
B80907 -
B80908 -
B80909 -
B80910 -
B80911 -
B80912 -
B810 -