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Workers' compensation mixup leads to surprise billing

In March 2001, I received a $223 bill from SDI Radiology for an OWCP (Office of Workers' Compensation Programs) X-ray done at a Tampa hospital Sept. 11, 2000. I called SDI and was informed that it was in the process of billing OWCP, so I should ignore the bill. I had never heard of SDI before I received this bill.

As a federal employee, I presented the emergency room physician, the X-ray tech and the pharmacy separate CA-16s at the time of service. A CA-16 is the government-authorized form for approved direct reimbursement for immediate treatment for a workers' compensation injury.

On June 17, I received a second bill from SDI, stating that I owed $174. Noticeably absent was date of service, OWCP number, etc. I immediately called, and a "Teresa" said she couldn't retrieve my file but a "Modessa," who is in charge of my file, would return my call post haste. No one called.

On June 18, I called SDI again and a "Desiree" said she couldn't help me, either, but that "Modessa" would call. She said the bill referred to a Sept. 11, 2000, workers' comp injury and provided an erroneous OWCP number. Modessa never called.

I then called the Office of Workers' Compensation Programs and was told SDI used an erroneous OWCP number for me. I was told to ignore any future SDI billings and that I did not owe a single cent.

I felt relieved, but I nevertheless fear SDI will turn this over to a collection agency, and then I will have myriad paperwork and problems as a result. Can you contact SDI and ultimately obtain for me a statement that reflects a zero balance? Robert Marcus

Response: Jeff Younger, chief executive officer of SDI Radiologists in Tampa, said there was confusion about your claim number and that two claim numbers had to be submitted for this bill. This has been clarified, corrected and resubmitted to the appropriate carrier. Younger said SDI's director of billing has contacted you about this issue, and he believes everything has been resolved.

It's time to file appeal

On Aug. 24, 2000, I was admitted to the hospital for a sleep disorder. The test was six hours long; I was discharged the same day. On Nov. 7, 2000, I received a summary statement showing a charge of $1,540. It stated that Medicare was billed for this. My primary insurance is Medicare.

My secondary insurance is Western-Southern Life Insurance Co., from which my wife retired. Western-Southern Life has always paid any balance that Medicare did not. The hospital had made copies of my Medicare card and my Western-Southern Life Insurance card, so I assumed it would bill Western-Southern Life for the amount Medicare did not pay.

On Feb. 5 of this year, I received a detailed statement showing patient responsibility of $275.07. I called the hospital and was told it had billed Western-Southern Life but would bill it again.

On March 7, I received a statement requesting payment of $275.07. I called and wrote to the hospital, asking it to file the claim again. On April 29, the hospital wrote back that it had filed the claim on five occasions. My wife then called Western-Southern Life in Cincinnati and was told it had never received a bill from the hospital.

On May 8, I received a statement from Western-Southern Life showing a claim for service on Aug. 24, 2000, and stating that charges were denied because of late filing. Thank you for any help or advice you can give me. Charles Phillips

Response: Dean Vonderheide, assistant vice president and director of Western-Southern Life's benefits department, said that because of privacy concerns, the company will discuss these matters only with you or your legal representative. That would not be us.

He did say that the summary plan description you receive annually and the explanation of benefits form sent with every claim explain how to appeal a disputed matter. There are time limits on filing appeals, and much of that time has been used filing your complaint with Action, he said.

Nonetheless, Western-Southern will allow you 60 days from the date of his letter (July 16) to file an appeal for any claim denied within the last 90 days. If you do not understand your rights under your benefit plan or how to file an appeal, you may call him toll-free at 1-800-333-1455, ext. 1176.

We suggest you immediately file an appeal with Western-Southern Life for the May 8 denial of the claim. If you are uncertain how to proceed, take Mr. Vonderheide up on his offer and give him a call.

Billing problems for medical services can be a nightmare to sort out, particularly as more providers and insurance carriers are added to the mix. With hindsight, you might have contacted Medicare, Western-Southern Life and the hospital when you did not receive any Medicare summaries or explanation of benefits after several months had elapsed after the test. Unfortunately, it is common for patients to discover they owe for medical services only after they've been turned over to a collection agency.

However, we're not sure whether being proactive in such instances is necessarily advisable, or even possible, because so many behind-the-scene providers can be involved. One other avenue to try is the state's department of insurance. Check the phone book under the listing for state offices.

Good luck with this problem. Let us know how it turns out.

Action solves problems and gets answers for you. If you have a question, or your own attempts to resolve a consumer complaint have failed, write Times Action, P.O. Box 1121, St. Petersburg, FL 33731, or call your Action number, (727) 893-8171, or, outside of Pinellas, toll-free 1-800-333-7505, ext. 8171, to leave a recorded request.

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