CONTACTS 

SUBJECTS
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0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 12 0000, ref SDS 11 0000.
040502 -
040503 -
040504 -
040506 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - On 071010 Millie received a letter dated 071006 from Paula notifying
040902 - that Kaiser has initiated internal administrative review by an MCRC
040903 - Appeals Committee of Kaiser's failure to pay for prescribed treatment.
040904 - ref SDS 10 TH8L  Paula advised in her letter on 071006 that the
040905 - Appeals Committee will have a meeting on her case withing 60 days, and
040906 - that Millie can appear or be represented to explain patient history.
040907 - ref SDS 10 813X
040909 -  ..
040910 - Millie has not actually filed an appeal.  Paula is a senior case
040911 - manager with MCRC.  Paula called on 071006 and reported receiving a
040912 - fax of 50 pages of background records, ref SDS 9 Z87L, which were
040913 - referenced in a letter sent to CMS on 071002, ref SDS 8 KA5J, and
040914 - asking whether Medicare law prohibits Kaiser from paying for
040915 - prescribed treatment. ref SDS 8 OY4Q
040917 -  ..
040918 - The propspect of appearing before a hearing raises questions of
040919 - representation and preparation.
040921 -  ..
040922 - Inquiries were made on 071010 for representation and to get
040923 - information about the level of preparation required for making an
040924 - appearance. ref SDS 11 X58I
040926 -  ..
040927 - Geoffrey White, Esq, was the only person who could discuss HMO,
040928 - Medicare insurance law; he agreed consult via email on the issue.
040929 - ref SDS 11 X58I
040931 -  ..
040932 - On 071015 a call back from an attorney's office who had considered the
040933 - case provided additional legal support sources. ref SDS 12 G25I
040935 -  ..
040936 - Additional calling eventually led to an organization calling back and
040937 - saying that if Kaiser failed to pay for prescribed treatment on
040938 - referral to UCSF, then they would like to be contacted about providing
040939 - legal representation. ref SDS 12 IJ7F
040941 -  ..
040942 - We still guidance on preparing for the meeting with the Kaiser Appeals
040943 - Committee, including responding to Paula's letter dated 071006,
040944 - received on 071010. ref SDS 10 TH8L
040946 -  ..
040947 - Millie wrote to her boss at N&P saying...
040948 -
040949 -    1.  Subject: Medical Payment Issue Kaiser
040950 -        Date: Mon, 22 Oct 2007 09:07:20 -0700
040957 -         ..
040958 -    3.  Hi - Chris has kept me up on things at the office.  Thanks to a
040959 -        new kind of treatment since January, I am stronger now, and
040960 -        thinking of returning to work.   The doctor wants to see a
040961 -        consistent pattern to release me for regular duty.  Keeping my
040962 -        fingers crossed.
040964 -  ..
040965 - This aligns with the letter to UCSF on 071019, ref SDS 13 JC6X, and to
040966 - Kaiser later today. ref SDS 14 X442
040968 -  ..
040969 - Letter to N&P continues...
040970 -
040971 -    4.  I'm hoping you can point me in a direction within the firm for
040972 -        comment on a payment dispute with Kaiser.  I realize this is
040973 -        not your bailiwick, but any thoughts are greatly appreciated.
040974 -        It's a little complicated, and N&P may have a conflict, if they
040975 -        represent Kaiser.  I will understand if I strike out on this.
040976 -
040977 -            [On 071112 called Sonia; she plans to review Millie's issue
040978 -            in the next few days and respond to the letter on 071022.
040979 -            ref SDS 15 MF7O
040981 -             ..
040982 -            [On 081112 Millie requests support for helping Kaiser
040983 -            approve Millie's next treatment at UCSF. ref SDS 16 I06J
040985 -         ..
040986 -    5.  Briefly, on Jan 5, 2007 my doctor prescribed treatment at UCSF
040987 -        in a clinical trial.  The doctor made arrangements on Dec 30,
040988 -        2006 in correspondence (email) with UCSF for Kaiser to pay any
040989 -        costs not covered by the clinical trial. ref SDS 1 PK68  My
040990 -        treatments started on Feb 1, ref SDS 3 0001, and after a month
040991 -        or so, weekly treatments proved very effective. [reported on
040992 -        070308. ref SDS 4 0001]
040994 -         ..
040995 -    6.  Eight months later, in August, I started getting a lot of
040996 -        invoices backdated to Jan [reported 070823, ref SDS 5 X16N]
040997 -        that add up to about $10K per year above my insurance premiums
040998 -        to Kaiser. [reported on 070830, ref SDS 6 W05N]  I was told by
040999 -        UCSF that Kaiser refused payment, because I am a Kaiser Senior
041000 -        Advantage patient.  Kaiser maintains people over 65 who are
041001 -        automatically covered by Medicare can "self-refer" to
041002 -        participate in clinical trials that advance medical science, so
041003 -        they don't have to pay for prescribed care by Kaiser.
041004 -        ref SDS 6 IR4F]  After this all happened in August, I started
041005 -        checking, and in September found that Kaiser had sent out an
041006 -        insurance booklet in January with "evidence of coverage" (EOC).
041007 -        [reported 070927, ref SDS 7 166L]  The EOC says in section 7 on
041008 -        page 68 that patients can "self-refer" to clinical trials
041009 -        anywhere in the country and without doctor approval [see
041010 -        ref SDS 7 1G4O] in order to advance medical science, [see,
041011 -        ref SDS 7 OU84] but have to pay 20% coinsurance. ref SDS 7 1F67
041013 -         ..
041014 -    7.  Of course I had never seen this because Kaiser all along for 6
041015 -        years had prescribed treatment in clinical trials and paid all
041016 -        the costs. [see case study on 070830, ref SDS 6 LQ5I]  When the
041017 -        doctor did the same thing this past January, I had no reason to
041018 -        doubt his prescription by looking into the general clauses on
041019 -        page 68 of the insurance policy.  I relied on my doctor to
041020 -        review requirements and prescribe treatment, as specified in
041021 -        Section 2 of the EOC. [reviewed on 070927, ref SDS 7 WS6M]
041023 -         ..
041024 -    8.  The dispute centers on "self-refer."  Can Kaiser's requirement
041025 -        to provide necessary care in section 2 of the EOC be avoided
041026 -        simply by prescribing treatment on referral to clinical trials,
041027 -        and then say the patient "self-referred", when the doctor made
041028 -        the referral?  While $10K is small potatoes for N&P, it has big
041029 -        potential for Kaiser.  If Kaiser's position stands, it provides
041030 -        a path for transferring huge costs from Kaiser insurance
041031 -        revenues to Medicare and to the patient by prescribing
041032 -        treatment in clinical trials.
041034 -         ..
041035 -    9.  The case seems to present possibly 16 issues. [listed on
041036 -        070927. ref SDS 7 WU6M
041038 -         ..
041039 -   10.  Kaiser has scheduled me for a hearing at a Regional Appeals
041040 -        Committee within 60 days of October 6th, as set out in a letter
041041 -        I received. ref SDS 10 TH8L
041043 -         ..
041044 -   11.  As you can see, I have not actually submitted a request for an
041045 -        appeal, because Kaiser has never said anything directly to me
041046 -        about "self-refer". ref SDS 10 O94J  Kaiser has sent me about
041047 -        60 letters saying they refuse payment to UCSF because the
041048 -        doctor did not submit authorization for treatment.  On January
041049 -        19th the doctor sent me a letter saying authorization was
041050 -        submitted. ref SDS 2 4R4M  So, evidently, someone higher up
041051 -        pulled the doctor's authorization, and I have not officially
041052 -        been told why, i.e., what authority countermands the doctor's
041053 -        order for treatment, and why wasn't this disclosed in January
041054 -        before costs were incurred?
041056 -         ..
041057 -   12.  This raises concern of getting caught up in big time medical
041058 -        machinations, i.e., way over my head.
041060 -         ..
041061 -   13.  I'm wondering if anyone on our team has experience with these
041062 -        hearings, and can offer pointers for appearance.  Do I need
041063 -        representation, can I call witnesses, should I submit a
041064 -        prepared statement, that sort of thing.  Has anyone researched
041065 -        Medicare law on clinical trials, or is this a new area coming
041066 -        up that Kaiser is positioning to handle the baby boomers?
041067 -
041068 -            [On 071112 called Sonia; she plans to review Millie's issue
041069 -            in the next few days and respond to the letter on 071022.
041070 -            ref SDS 15 MF7O
041072 -         ..
041073 -   14.  Again, I realize N&P may not be able to help.
041074 -
041075 -
041077 -  ..
0411 -
0412 -
0413 - 1110
0414 -
041401 - Millie received a reply from Sonia saying...
041402 -
041403 -    1.  Subject: Medical Payment Issue Kaiser
041404 -        Date: Mon, 22 Oct 2007 12:17:17 -0400
041408 -         ..
041409 -    2.  Hi Millie,
041411 -         ..
041412 -    3.  I'll take a closer look at this later today and do some
041413 -        investigating.  I'll get back to you soon.  Hope to see you
041414 -        back here soon!!!
041415 -
041416 -            [On 071112 called Sonia; she plans to review Millie's issue
041417 -            in the next few days and respond to the letter on 071022.
041418 -            ref SDS 15 MF7O
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0415 -