CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 12 0000, ref SDS 9 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Glenna said she has received from Doctor Johnson at Kaiser reports on
040902 - the 4 medical tests UCSF ordered, so Millie is all set to start
040903 - treatment tomorrow.
040905 -  ..
040906 - Glenna said there is a problem.  She has not received authorization
040907 - from Kaiser, which Doctor Johnson submitted, reported in her call on
040908 - 081031, ref SDS 10 5C7J, and confirmed in Glenna's letter later that
040909 - day on 081031. ref SDS 11 458L
040911 -  ..
040912 - Suggested Glenna call Paula at Kaiser in Member Relations.  Paula
040913 - issued the letter dated 071130 authorizing payment for Millie's
040914 - treatment of referral by Kaiser with the cetuximab Carboplatin study.
040915 - ref SDS 5 TH8L
040916 -
040917 -            [...below, called Paula and she confirmed Millie's doctor
040918 -            ordered authorization on 081103 for her treatment at UCSF
040919 -            in the sunitinib clinical study, and Kaiser management sent
040920 -            a denial to him on 081110; Paula suggests contacting
040921 -            Expedited Claims to maintain continuity of Millie's
040922 -            treatment ordered by her doctor, schedule to start
040923 -            tomorrow. ref SDS 0 PQ35
040925 -             ..
040926 -            [...below, Michelle in Expedited Claims advises that
040927 -            Millie's doctor is in charge of her treatment, and Kaiser
040928 -            must implement the doctor's orders. ref SDS 0 P28U
040930 -  ..
040931 - Glenna will try to find out how much UCSF will charge for Millie's
040932 - treatment.
040934 -  ..
040935 - We may not be talking about a lot of money.  The problem is that
040936 - billings were previously incomprehensible, and nobody at UCSF could
040937 - explain them.
040938 -
040939 -
040940 -
040942 -  ..
0410 -
0411 -
0412 - 1011
0413 -
041301 - Called Arlette.
041302 -
041303 - Arlette said she has submitted to Glenna at UCSF via fax results of
041304 - Millie's medical tests requested in Millie's letter to the doctor on
041305 - Monday, and followed up this morning.
041307 -  ..
041308 - Arlette will ask Doctor Johnson to send the reports to Millie for
041309 - review to prepare for meeting with the doctor tomorrow.
041310 -
041723 -
041725 -  ..
0418 -
0419 -
0420 - 1119
0421 -
042101 - Millie received a letter from Glenna saying...
042102 -
042103 -    1.  Subject: T/C with Paula at Kaiser
042104 -        Date: Wed, 12 Nov 2008 11:01:59 -0800
042111 -         ..
042112 -    2.  Your phone was busy and I have to run to clinic so thought I'd
042113 -        send an email.
042115 -         ..
042116 -    3.  Paula called back and said that you would have to submit an
042117 -        appeal for authorization.
042119 -         ..
042120 -    4.  The only other option is to accept the 20% share of cost with
042121 -        Medicare.  I will try to get an idea of how much $ we are
042122 -        looking at for you, but for now this is where things stand.
042123 -
042124 -            [...below, called Paula at Kaiser. ref SDS 0 PQ35
042126 -         ..
042127 -    5.  I would encourage you to send the appeal in if this is the
042128 -        direction you want to take.
042130 -         ..
042131 -    6.  I'll try back later when I return from clinic.
042132 -
042138 -
042139 -
042509 -        To: "Millie Buck"
042511 -         ..
042541 -
042542 -            [...in another record today on 081112, Millie submitted
042543 -            background on the dispute with Kaiser in order to find
042544 -            assistance with expertise dealing with Kaiser/Medicare and
042545 -            clinical trial referral issues. ref SDS 13 I06O
042546 -
042551 -
042552 -
042554 -  ..
0426 -
0427 -
0428 - 1154
0429 -
042901 - Called Paula at Kaiser, per UCSF recommendation in Glenna's letter
042902 - today, shown above. ref SDS 0 TL9R
042904 -  ..
042905 - Paula recalls her letter to Millie on 071128 showing Kaiser agreed to
042906 - pay for Millie's treatment on referral at UCSF in the triple negative
042907 - study, ref SDS 5 TH8L, including coinsurance of 20% for standard of
042908 - care expense cited in EOC section 7, reviewed on 070927. ref SDS 4
042909 - 1F67
042911 -  ..
042912 - Paula checked Kaiser's computer and advised that on 081103 Doctor
042913 - Johnson ordered Millie's treatment at UCSF in the sunitinib clinical
042914 - study, and submitted authorization for payment to UCSF for referral
042915 - care services.  This aligns with Glenna's call this morning reporting
042916 - that Kaiser notified UCSF on 081103 that authorization was submitted,
042917 - per above. ref SDS 0 ZX8F
042918 -
042919 -            [...in another record today on 081112, Millie submitted
042920 -            background on the dispute with Kaiser in order to find
042921 -            assistance with expertise dealing with Kaiser/Medicare and
042922 -            clinical trial referral issues. ref SDS 13 I06O
042924 -  ..
042925 - This aligns with the doctor's representation to Millie on 080829, set
042926 - out in Millie's letter confirming the meeting at Kaiser. ref SDS 6
042927 - RP8T  During the next meeting at Kaiser on 081024, the doctor entered
042928 - into the medical chart referral to UCSF, shown in Millie's letter to
042929 - the medical team. ref SDS 8 XZ8W  On 081031 Glenna reported that
042930 - Doctor Johnson agreed to authorize Millie's referral to UCSF for
042931 - treatment. ref SDS 10 5C7J  This was confirmed by UCSF letter later
042932 - that day on 081031. ref SDS 11 458L
042934 -  ..
042935 - Paula said the Kaiser computer shows that on 081110 somebody at Kaiser
042936 - denied authorization and refused to perform the doctor's order for
042937 - Millie's care.
042939 -  ..
042940 - The facts in the current situation are the same.
042942 -  ..
042943 - Paula said that overturning denial of payment for referral services
042944 - requires Kaiser to issue another appeals determination, like her
042945 - letter on 071128. ref SDS 5 TH8L  Paula feels Kaiser will have to
042946 - issue another approval to pay for the sunitinib study, based on the
042947 - doctor's order on 081103.
042948 -
042949 -            [...in another record today on 081112, Millie submitted
042950 -            background on the dispute with Kaiser in order to find
042951 -            assistance with expertise dealing with Kaiser/Medicare and
042952 -            clinical trial referral issues. ref SDS 13 I06O
042954 -  ..
042955 - Paula explained that since Millie needs treatment to start tomorrow,
042956 - there is not enough time for a standard appeal.
042958 -  ..
042959 - Paula suggested calling Expedited Claims Department.
042960 -
042961 -             888 987 7247
042963 -  ..
042964 - Paula advised that any refusal by Expedited Claims is automatically
042965 - sent to her department for thorough review.
042966 -
042967 -        [...below, Michelle advises that Expedited Claims denied
042968 -        coverage for the referral Kaiser made in this case, ref SDS 0
042969 -        P28U, and that the doctor is charge of Millie's health care,
042970 -        and that Kaiser must implement the doctor's order for Millie's
042971 -        care. ref SDS 0 PR35
042972 -
042973 -
042974 -
042976 -  ..
0430 -
0431 -
0432 - 1210
0433 -
043301 - Called Expedited Claims Department........ 888 987 7247
043302 -
043303 - Talked to Venitia.
043305 -  ..
043306 - Venitia took down Millie's
043308 -  ..
043309 - Venitia described Millie's claim as for denial of oncology services.
043311 -  ..
043312 - After taking down patient identification, Venitia said she will
043313 - submit this to a claims analyst.  The analyst will call back this
043314 - afternoon to get specific patient history and process an expedited
043315 - claim.
043316 -
043317 -
043319 -  ..
0434 -
0435 -
0436 - 1516
0437 -
043701 - Michelle Burrill........ 888 987 7247 ext 2115
043702 -
043703 - Gave Michelle background on Millie's case, per telecon with Paula,
043704 - shown above. ref SDS 0 PQ35  Explained Paula's suggestion to call
043705 - Expedited Claims, since Millie has a meeting scheduled with UCSF
043706 - tomorrow that presents obligations for payment which Kaiser must
043707 - perform.
043709 -  ..
043710 - Michelle asked when Millie learned that Kaiser was refusing to pay for
043711 - her care?
043713 -  ..
043714 - Advised UCSF called and disclosed the problem at 1000 this morning,
043715 - per above. ref SDS 0 FJ5J
043717 -  ..
043718 - Discussed difficulties Kaiser's 11th hour failure to perform presents
043719 - for the patient who must review 4 medical test reports to prepare for
043720 - an effective meeting tomorrow, and now must deal with accounting
043721 - issues, wholly unrelated to requirements for care.
043723 -  ..
043724 - Michelle will call Paula for assistance getting background Kaiser's
043725 - approval for the prior claim to pay for Millie's referral to UCSF in
043726 - 2007.
043728 -  ..
043729 - Michelle will discuss Millie's case with the doctor who can approve
043730 - Expedited Claims, and call later today with results.
043731 -
043732 -
043733 -
043734 -
043736 -  ..
0438 -
0439 -
0440 - 1617
0441 -
044101 - Glenna called.
044102 -
044103 - She reported getting a message on her answering machine from Michelle
044104 - at Kaiser saying she (Glenna on behalf of UCSF) should tell Millie to
044105 - call Medicare.
044107 -  ..
044108 - Glenna seemed to indicate she has received reports from Arlette on
044109 - all four tests ordered by UCSF and performed at Kaiser required for
044110 - Millie to start treatment tomorrow.
044112 -  ..
044113 - Glenna had not reviewed the CT test on 081107.  While we talked she
044114 - looked at the report from Kaiser and noticed the mistake comparing the
044115 - test on 081107 with the test on 080718, rather than the more recent
044116 - test on 080911.
044118 -  ..
044119 - Glenna further noticed the report for the test on 081107 described
044120 - adenopathy in the right supraclavicular rather than the left
044121 - supraclavicular.
044123 -  ..
044124 - Advised that Millie has contacted the doctor at Kaiser to request
044125 - clarifications.
044127 -  ..
044128 - Glenna seemed to say that UCSF will start Millie's treatment tomorrow
044129 - regardless of Kaiser's sudden failure to perform today the doctor's
044130 - order for Millie's care on referral to UCSF.  This was good news
044131 - providing time to sort things out.
044132 -
044133 -
044135 -  ..
0442 -
0443 -
0444 - 1620
0445 -
044501 - Michelle called back.
044502 -
044503 - She said someone at Kaiser today changed the doctor's order on 081103
044504 - for Millie's urgent care on referral at UCSF scheduled to begin
044505 - tomorrow on 081113 0800.  This confirms Paula's report, per above.
044506 - ref SDS 0 UV4O  Michelle advised that she was told Kaiser refuses to
044507 - pay for Millie's health care on referral to UCSF because the doctor
044508 - ordered treatment in a clinical trial, and since Millie is a Medicare
044509 - patient, she can choose to self-refer for treatment in clinical
044510 - trials.  Michelle was told that someone at Kaiser feels Kaiser has no
044511 - responsibility for Millie's care, if the doctor orders treatment in a
044512 - clinical trial, even in this case when the doctor orders continuing
044513 - care the past 2 years on referral to a clinical trial, and the patient
044514 - has not self-referred.
044516 -  ..
044517 - Michelle advised that Millie's primary care doctor is in charge of her
044518 - care at Kaiser.  She stated that the doctor is responsible to perform
044519 - case management under section 2 of Kaiser's EOC, reviewed on 070927,
044520 - ref SDS 4 WS6M, including in this case the doctor's referral for
044521 - Millie's treatment to UCSF.  Michelle said the doctor has authority to
044522 - interface will all affected organizations required to implement
044523 - prescribed treatment, including Kaiser's Referral Department, the
044524 - Pharmacy, the Billing Department, testing, Labs, Medicare, and UCSF.
044525 - The patient is insulated from these complexities of case management in
044526 - order to ensure prescribed care is provided in time to be effective.
044527 - She said that Kaiser is required to implement the doctor's order for
044528 - patient care covered by the EOC.
044530 -  ..
044531 - Michelle confirmed that oncology is covered by the EOC in Millie's
044532 - insurance agreement with Kaiser.
044534 -             ..
044535 -            [...below, on 081112 1643 Doctor Johnson reported ordering
044536 -            authorization for payment of Millie's treatment on 081103,
044537 -            and somebody else sent a denial on 081110, showing conflict
044538 -            with Michelle's guidance that the doctor is in charge of
044539 -            patient care. ref SDS 0 TH49
044541 -  ..
044542 - During the call, we noticed that Michelle's comments today align with
044543 - HHS Publication No. 00-PO38 issued by the Agency for Healthcare
044544 - Research and Quaity (AHRQ) which requires a single doctor to be in
044545 - charge of managing the patient's care, reviewed on 041113. ref SDS 2
044546 - JH3Q
044547 -
044548 -            [...in another record today on 081112, Millie submitted
044549 -            background on the dispute with Kaiser in order to find
044550 -            assistance with expertise dealing with Kaiser/Medicare and
044551 -            clinical trial referral issues. ref SDS 13 I06O
044553 -  ..
044554 - Millie's request for relief today from the Expedited Claims department
044555 - is for Kaiser to implement EOC provisions according to pattern and
044556 - practice Kaiser has followed caring for Millie, shown by patient
044557 - history in this case.
044559 -  ..
044560 - We considered briefly that the record in this case shows that on
044561 - 081110 Kaiser failed to perform the doctor's order on 081103 for
044562 - Millie's treatment at UCSF.
044563 -
044564 -     [...below Doctor Johnson calls and repeats for the first time ever
044565 -     in 7 years that Millie should call Medicare about the doctor's
044566 -     order for her treatment. ref SDS 0 0D4H
044568 -  ..
044569 - Michelle said she was told by her boss that Medicare patients getting
044570 - treatment in clinical trials must call...
044571 -
044572 -             800 Medicare
044573 -
044574 - ...rather than rely on their doctor for coordination under EOC
044575 - section 2.
044577 -  ..
044578 - Michelle did not say what patients say after dialing the number.
044580 -  ..
044581 - Asked Michelle for authority that requires Millie to call Medicare
044582 - about Kaiser's failure to preform the doctor's order for her care?  In
044583 - seven (7) years of care for cancer, Millie has never been required to
044584 - call Medicare to implement the doctor's treatment plan.  The doctor
044585 - has at all times arranged and coordinated her care.  Who told Michelle
044586 - to tell the patient to call Medicare, and on what grounds?  Kaiser's
044587 - EOC reviewed on 070927 says the primary care physician coordinates
044588 - patient care. ref SDS 4 WS6M
044590 -  ..
044591 - Michelle said this is a little confusing for patients, but her boss
044592 - told her that all she can say to Millie for resolving patient request
044593 - for Expedited Claim Review is that Millie should call Medicare not
044594 - Kaiser to adjust Kaiser's failure to perform requirements of EOC
044595 - section 2.
044596 -
044597 -            [...in another record today on 081112, Millie submitted
044598 -            background on the dispute with Kaiser in order to find
044599 -            assistance with expertise dealing with Kaiser/Medicare and
044600 -            clinical trial referral issues. ref SDS 13 I06O
044602 -  ..
044603 - Michelle did not say a report would be issued to Millie, and would be
044604 - sent to Paula's department for review, as Paula mentioned this
044605 - morning, per above. ref SDS 0 4Q78
044607 -  ..
044608 - Thanked Michelle for expedited review.
044609 -
044610 -
044612 -  ..
0447 -
0448 -
0449 - 1643
0450 -
045001 - Doctor Johnson called.
045002 -
045003 - Thanked the doctor for submitting 4 test reports to UCSF today in time
045004 - for people to prepare for Millie's meeting tomorrow, per Glenna's
045005 - report above. ref SDS 0 FJ5J, and for sending 2 of the reports on the
045006 - CT and brain MRI to Millie through Kaiser's internal mail system.
045008 -  ..
045009 - The doctor said he got Millie's letters about mistakes in the CT test
045010 - report, and seemed to indicate having forwarded them to the CT
045011 - department for correction, in time for review tomorrow during the
045012 - meeting with Doctor Rugo at UCSF.  He has not had time to send the
045013 - report on the biopsy to test status change, nor the echocardiogram,
045014 - but will get those to Millie later this evening.
045016 -  ..
045017 - The doctor initially began an explanation by repeating what Michelle,
045018 - in Expedited Claims, just gave about Medicare patients can self-refer
045019 - for treatment in clinical trials, and so should call Medicare rather
045020 - than rely on the doctor. ref SDS 0 Z65I
045022 -  ..
045023 - Sounded like he had been called and told to call the patient and say
045024 - something never previously told to the patient and wholly confliciting
045025 - with the doctor's order for Millie's care issued on 081103 to
045026 - implement direction to the patient on 080829, and on 081024.
045028 -  ..
045029 - We reviewed patient history over the past 7 years, showing the doctor
045030 - has never previously advised Millie to call Medicare.  The doctor at
045031 - all times has prescribed essential care, ordered treatment required to
045032 - implemented care by making referrals under team care practices at
045033 - Kaiser.
045035 -  ..
045036 - For example, on 040318 the doctor described clinical trials as
045037 - essential to the doctor's "medical kit" for treating cancer patients.
045038 - ref SDS 1 PU6M  At that time, the doctor insisted Millie approve
045039 - treatment in a clinical trial, and Millie was not charged 20%
045040 - coinsurace nor asked to call Medicare.
045042 -  ..
045043 - What's the difference now?
045045 -  ..
045046 - Today, the doctor explained that oncology practice at Kaiser is under
045047 - a lot of pressure to care for terminal patients within a budget.
045048 -
045049 -     [On 090213 1140 Doctor Johnson used an ancient Indian fable to
045050 -     explain costs of Millie's fight against cancer have greatly
045051 -     exceeded expectations, ref SDS 16 4N5K, because Kaiser has done a
045052 -     good job in this case enabling survival for 7 years that usually
045053 -     causes death within 3 years. ref SDS 16 4N67
045055 -  ..
045056 - The doctor further confirmed having submitted referral authorization
045057 - on 081103 for Millie's treatment at UCSF, as reported by Paula
045058 - earlier, per above. ref SDS 0 UV4O  The doctor also advised of having
045059 - received a denial on 081110 stating Kaiser refused to perform the
045060 - doctor's treatment plan.  He investigated and was told that Kaiser
045061 - does not have to pay for patient care when the doctor prescribes
045062 - treatment on referral to a clinical study, because Medicare
045063 - regulations enable patients to self-refer for treatment in a clinical
045064 - trial.
045066 -  ..
045067 - We reviewed background on Kaiser's requirement to care for Millie
045068 - based on patient history, reviewed in detail on 070927. ref SDS 4 WU6M
045070 -  ..
045071 - We considered briefly that Medicare entitlement to self-refer allows
045072 - patients relief from the doctor's treatment plan by expanding
045073 - opportunities beyond a single provider.  Kaiser seeks to use this
045074 - Medicare patient benefit as a shield for the provider to avoid 100% of
045075 - the cost for patient care by insisting that when patients follow the
045076 - doctor's prescription for treatment in a clinical trial, this is
045077 - twisted into an interpretation of "self-referral" that relieves Kaiser
045078 - of obligation, reviewed further in the record on 070927. ref SDS 4
045079 - WU6M
045081 -  ..
045082 - Suppose Millie cannot afford $20 - $30K per year for 20% of the cost
045083 - for the clinical trial.  Suppose she does not have time, energy, nor
045084 - expertise to review complex billings that grossly overcharge.  What
045085 - treatment does Kaiser propose after already having determined that the
045086 - best course of care is the clinical study for sunitinib at UCSF?  At
045087 - this point, Kaiser is out of treatments for Millie.  How does Kaiser
045088 - perform it's duty of care in section 2 of the EOC? ref SDS 4 WS6M
045089 -
045090 -
045091 -
045093 -  ..
045094 - Doctor in Charge Patient Care Small Cog Big Wheel Kaiser Management
045095 - Small Cog Big Wheel at Kaiser Doctor Responsible Patient Care No Authority
045096 -
045097 - Discussed Michelle's point in her call a few minutes ago, per above,
045098 - that the primary care physician is in charge and can order the care
045099 - Millie needs. ref SDS 0 P28U
045101 -  ..
045102 - The doctor said he ordered Millie's care in the sunitinib clinical
045103 - study at UCSF, noted in her medical chart on 081024.  He submitted
045104 - authorization for prescribed care on 081103, and he got a denial from
045105 - Kaiser management on 081110 for the care he ordered on 081103.
045107 -  ..
045108 - The doctor described being a small cog in a big wheel, and is
045109 - powerless to direct care for Millie, beyond issuing the referral,
045110 - which he did on 081103, as noted in the medical chart for the meeting
045111 - on 081024.
045113 -  ..
045114 - This seems starkly conflicting with Michelle's advice today that
045115 - Kaiser must implement the doctor's order for patient care, per above.
045116 - ref SDS 0 P28U
045118 -  ..
045119 - Thanked the doctor for calling, and agreed to keep working this issue.
045120 -
045121 -
045541 -
045542 -
045543 -
045544 -
045545 -
045546 -
0456 -