Saul Ramos, debilitated by Alzheimer’s, could no longer work as a mason. Money was getting tight and he and his family were counting on him qualifying for Social Security disability benefits.

So when a Social Security judge raised questions about whether the 62-year-old Honolulu native had experienced symptoms as far back as 2015, his lawyer, Danielle Beaver, came up with a plan.

She typed up a two-question form for him to take to his doctor.

Had Ramos been experiencing symptoms in late 2015? The form left a small space for an explanation. And would there be a medical explanation for Ramos’ denying he was having cognitive problems?

Ramos’ doctor at Kaiser Permanente Hawaii routed the request through the legal department, which responded that the doctor could do the report. But it would take an hour of the doctor’s time.

The cost: $350.

Sandra Ramos and Saul Ramos enjoy a quick kiss as Sandra remarked, “Saul and I were meant to be”. Saul has been sufferering from Alheimers and demetia for a while now.

Sandra Ramos and Saul Ramos, who suffers from Alzheimer’s, enjoy a quick kiss. The Ramos’ attorney is challenging the fees Kaiser Permanente charges to get doctors to fill out a form for Social Security disability payments.

Cory Lum/Civil Beat

Beaver, one of the few Hawaii lawyers who focuses on Social Security disability,  says that Kaiser is the only provider that charges more than a nominal fee for a doctor to fill out such forms — a heavy burden for clients who are struggling with illness and drastically reduced income, some of whom may be homeless or close to it.

Several other providers contacted by Civil Beat confirmed that they would not charge for answering questions for a disability applicant.

Kaiser, however, says it is following industry standards in covering the costs of doctors’ time, and that Beaver is the only attorney who refuses to honor its process of routing requests through its legal department.

Workers sidelined by disease or injury who claim Social Security disability benefits may have to wait two years or more before seeing any money. During that time, strict rules limit how much they can earn, assuming they can work at all. Social Security also pays those with very low incomes who are blind or disabled. More than 35,000 Hawaii residents qualify for one or both.

The financial squeeze for those who are waiting to qualify can be painful. Beaver hears the stories of workers hampered by everything from cancer to multiple sclerosis to amputations from diabetes.

“A couple of times a year, a client will die while they’re waiting,” she said. “I get so many calls – `I’m going to lose my house. I’m living on my friend’s couch. I’m sleeping in the street.’”

As the case drags on, an administrative law judge in a hearing may ask for clarification about the workers’ medical condition. When did the disability start? How long can the person sit or stand? How much can they lift?

Kaiser charges the patient for the doctor’s time. And in Beaver’s experience, that adds up to $350 to $500.

Beaver is fighting Kaiser over the charges. It’s come up only a handful of times so far. But Kaiser wants to force the attorney to agree to relay all future requests through the corporation’s legal department, which has a policy of charging for the doctor’s time.

With 200 clients a year awaiting a disability hearing, Beaver fears the policy will either prevent them from getting the doctor statements key to winning their cases or force them to pay fees they can ill afford.

Kaiser said that other attorneys comply with the requirement to go through the legal department. That means an unknown number of disability claimants are paying fees as well.

Sandra Ramos with her husband Saul Ramos in their living room in Mililani. Saul has been suffering from Alheimer’s disease for a while.

Sandra Ramos with her husband, Saul, in their living room in Mililani. Kaiser Permanente wanted to charge the couple $350 for paperwork that other medical organizations provide for free or at a nominal cost.

Cory Lum/Civil Beat

“Kaiser’s mission is to get their patients as healthy as possible,” Beaver said. “They’re preventing that by being money grubbing.”

Kaiser spokeswoman Laura Lott told Civil Beat that the health care provider asks all attorneys, or members represented by lawyers, to work through the legal department on requests for reports, depositions and the like, including forms related to Social Security disability benefits.

The policy allows Kaiser to make sure it has proper authorization for disclosing medical information and to be more efficient in scheduling doctors’ time.

“We do charge reasonable fees for our doctors’ time,” she wrote.

Fees in other disability cases would depend on the doctor’s hourly rate, so Lott could not say if they were in the range of  $350 to $500 that Beaver’s clients have been charged.

Not The Norm?

But several other health care systems and clinics said they do it for free.

“Our clinics don’t charge for that kind of paperwork,” said Kristen Bonilla, spokeswoman for Hawaii Pacific Health, which runs Straub Medical Center and Wilcox Medical Center.

Neither does The Queen’s Medical Center, Waianae Coast Comprehensive Health Center or Kokua Kalihi Valley Comprehensive Family Services.

“We fill out a lot of paperwork that we don’t charge for,” said Laura DeVilbiss, a doctor at Kokua Kalihi Valley.

Beaver said unlike the other medical providers, Kaiser fails to distinguish between a doctor answering a few questions in writing for a patient during a regular office visit and other types of complicated and messy legal proceedings, such as medical malpractice claims or workers’ compensation cases.

By contrast, Social Security claims are conducted in informal, non-adversarial hearings, Beaver said. Social Security will not challenge the legality of the doctor’s opinions, she said. Nor are the doctors in danger of being cross-examined or deposed.

Even at Kaiser, Beaver said, many doctors will do the paperwork for free.

It’s only when the requests get routed to the corporation’s legal department that the charges kick in.

In late 2015, for instance, Kaiser billed Beaver’s client $500 for a doctor to fill out a five-page questionnaire about a patient. The form asked questions such as whether the patient would likely miss time from work because of pain and disability or take unscheduled breaks during an 8-hour shift.

Most of the questions could be answered by checking a box. A few required a written response of a few words.

Kaiser had another requirement – that Beaver sign an agreement to always go through the legal department, rather than having her clients go directly to their doctors.

“You have been previously instructed that communication and legal requests to the physicians of the Hawaii Permanente Medical Group should be directed to this office and not the individual physician,”  wrote George Apter, Hawaii Permanente Medical Group’s general counsel.

Beaver’s client paid the $500 and Kaiser never followed through on making her sign the agreement.

The Beginning Of Alzheimer’s

But earlier this year, the dispute erupted again in Ramos’ case.

Ramos worked his whole life as a mason, often fixing other workers’ mistakes, his wife Sandra said. The two married after knowing each other for many years, after Sandra’s first husband died.

“He was really sweet,” she said. “He took my mind off my husband who passed.”

In 2014, he was sent to a new job site. Sandra was surprised a few hours later to find him at home. He couldn’t find the place. He called his union representative, who was perplexed at how a reliable worker could get so lost.

“He sat down and just looked confused,” Sandra recalled.

Several months later, he couldn’t find his car in Waikiki.

“People that had known him for years said he looked lost,” Sandra said. “And when people look lost, the first thing people will think is drugs.”

In 2016 came a different explanation: Alzheimer’s.

“He didn’t want to admit it,” his wife said. “He was really in denial.”

After he made his Social Security claim, the judge wanted to establish that Ramos had been succumbing to Alzheimer’s as far back as 2015, leading to Beaver’s two-question form and the $350 charge.

Beaver found it hard to believe the form would take that long.

“They’re supposed to know their patients,” Beaver said. “If they can’t answer a question like, ‘Would this person have a hard time walking?,’ they shouldn’t have to spend an hour of their time reading their chart to answer that question.”

Still, the case was urgent enough that Ramos’ family’s was willing to pay the $350. Then came a kicker: Kaiser once again wanted Beaver to sign an agreement that she would send all future requests through the legal office.

Beaver refused, calling Kaiser’s policy “unconscionable.”

She believes that signing the agreement would have obligated all her future clients to pay in the range of $500 or more to get the information they needed from their doctors.

“I’m not going to put my clients in that kind of bind,” she said.

It turned into a moot point when the Social Security judge ruled in favor of Ramos without ever getting the questionnaire from his doctor. As a result, Ramos will not only get disability payments but also qualifies for Medicare, which gives him a much greater choice of doctors.

Beaver points out that disability clients who qualify for Medicare or Medicaid, funded by the federal government, are no longer depending on state benefits, cutting costs for state government.

Beaver said the dispute is unlikely to go away. The issue has come up repeatedly with Kaiser since 2012, when she took over the practice from her stepfather, who had problems even before that.

Lott, the Kaiser spokeswoman, said another reason for the policy is to assure that Kaiser has the proper patient authorization to disclose information to the attorney.

But Beaver doesn’t buy that explanation, either. It’s the patient, not the lawyer, who is handing the paperwork to the doctor and getting it back. And Beaver also provides a medical release authorization form for her clients to take to the doctor.

In addition, some doctors, especially those from Kaiser, simply refuse to fill out the forms, according to Beaver and Diane Haar, an attorney who also does disability cases.

No disability judge has ever expressly ruled against one of her claimants because of the lack of a doctor’s statement, Beaver said. But she worries it could sabotage some of her cases.

The consequences of losing a disability case can be grave. Beaver is haunted by one client, who had severe psoriasis. He lost the case, and around that time, became homeless and severely depressed. He contracted an infection, probably as a result of his skin being so irritated, and died.

“I really believe that if he’d had money and a place to live,” Beaver said, “he wouldn’t have died.”

In many cases, Social Security initially rejects the disability claims.

“Then, once they finally get to be heard by a judge to prove their disability in order to get financial help and health care, Kaiser tells them that they cannot help them unless they cough up hundreds of dollars,” Beaver wrote in an email.

“I just can’t stand by and watch this happen.”

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