Third-Party Administrator (TPA) ESIS completely failed to respond to multiple electronic bills (e-bills) for an injured Allied Universal employee’s treatment by the legally mandated deadline. When daisyCollect agents reached out for an explanation, ESIS sent us on a chase for an unreachable claim adjuster with a full voicemail box.

As of this writing, the provider has received no payment for ten compliant bills the provider sent for treatment that ESIS authorized.

According to an ESIS representative, the TPA is waiting on approval from the adjuster before releasing payment. ESIS has received and reviewed the bills in question, but this adjuster has apparently not taken the necessary action for the TPA to fulfill its legal obligation to either pay the bills or issue a timely, compliant denial with an Explanation of Review (EOR).

When our agents finally secured contact information for this adjuster, our calls went unanswered, and there was no way to leave a message.

ESIS is in violation of California workers’ comp payment laws and regulations, and owes this provider either full reimbursement or a formal denial that the provider can dispute. Moreover, ESIS (and the employer) will owe penalties and interest payments that are currently accruing.

If this is how ESIS handles its obligations to providers, it’s reasonable to wonder how this TPA treats the injured workers whose health and livelihoods are at stake.

ESIS Ignores Bills, Makes Adjuster Hard to Reach

Under California law, payers have 15 working days to respond to an electronic bill (e-bill) with an electronic Explanation of Review (e-EOR) and appropriate payment.

Whether or not the payer denies reimbursement, a timely e-EOR must post the required remittance advice to the provider’s e-billing system so that the provider can take appropriate action. Yet, for ten different bills on a single injured worker’s claim, ESIS has responded with nothing but silence.

When the provider resubmitted the e-bills in question, ESIS, confoundingly, denied them as duplicate submissions (which of course, they were, since ESIS ignored the originals). daisyCollect contacted ESIS, a representative of which told us that “We're done reviewing the bill. We forwarded it to the adjuster for the payment approval, but I think [it’s] still pending approval.”

The ESIS representative gave us the adjuster’s name, but could provide no contact information whatsoever. Instead, the ESIS rep directed our agent to call a local ESIS office to obtain contact information.

In another unprofessional twist, the local ESIS office had the adjuster's direct telephone number but no email address. When our agents called the adjuster’s direct line (twice), a recorded message noted that the adjuster would be out of the office until May 26, which was nearly seven weeks ago as of this writing:

“You’ve reached the voicemail of [adjuster]. I will be out of the office as of Tuesday May 19th and we'll be returning on Tuesday May 26th. Please keep in mind that Monday May 25th is a holiday and our office is closed. We will resume our normal business hours on Tuesday May 26. If you need immediate assistance, please contact our customer service at 1-800-654-5374. Thank you.”

In a final, gobsmacking turn, there was no way to leave a voicemail, as the adjuster’s voicemail box was full.

One person has the power to fulfill ESIS’s legal obligation or explain why the TPA has failed to do so thus far. That person:

• Cannot be reached by email (at least by providers) that we know of
• Has not answered multiple phone calls
• Has an outgoing voicemail message that is outdated by well over a month
• Has a voicemail box that has run out of storage, presumably choked with other inquiries ESIS has failed to address

ESIS: Consistently Violating e-EOR Requirement

daisyBill’s free Claims Administrator and Network Directory offers insights into all of the payers in our system, including their Electronic Data Interchange (EDI) performance and compliance with California laws and regulations.

The Directory assigns each payer an EDI “Grade” for how competently and compliantly they handle providers’ e-bills. ESIS has a Grade of F, driven almost entirely by its failure to send compliant e-EORs in response to e-bills.

e-EORs are a requirement in multiple states, and for good reason: without one, a provider's billing technology can't post payment details, leaving administrative staff stuck reconciling payments (or denials) manually. Most importantly, e-EORs close the payment loop, which ESIS has failed to do in this case on ten separate bills.

TPAs that make it difficult to obtain reimbursement for authorized care are not only doing a disservice to providers. They are contributing to the broader problem of workers’ comp, in which providers make the rational decision to avoid comp patients rather than face the payment burden that companies like ESIS impose on practices.

For employers, the net effect is reduced access to care, longer claim durations, higher disability costs, and lost productivity. ESIS isn’t the only TPA helping to degrade the system, but they’re certainly doing their part.

daisyBill gets providers paid faster and more accurately for injured workers’ treatment. Click below to see how:  

BILL BETTER: DAISYBILL