AmTrust North America is breaking the law. We encourage the California Division of Workers’ Compensation (DWC) to assert its role in upholding workers’ comp law and to impose appropriate consequences on this claims administrator for its blatant disregard of e-billing requirements.

Over the course of 2021, AmTrust failed to send 31,514 electronic Explanations of Review (e-EORs) in response to daisyBill providers’ e-bills.

Below is the message and formal Audit Complaints daisyBill submitted to the DWC on our provider clients’ behalf, documenting and reporting the astonishing scope of AmTrust’s violations.

Claims administrators cannot be allowed to wield the power of a phantom regulatory authority, free to ignore or adhere to laws as they please. California legislators and the DWC should penalize AmTrust for presuming to pick and choose which legal requirements suit its own purposes.

As non-compliant claims administrators too often demonstrate, regulation without consequences is merely a thin facade of the rule of law.

To: XXXXXXX@dir.ca.gov

Subject: AmTrust - X12 835 Missing: 2021 EDI Noncompliance Data

Below is an Audit Complaint reporting credible data that AmTrust failed to send 31,514 electronic EORs (X12 835) to California providers as mandated by California law. This Audit Complaint data represents California workers’ comp e-bills submitted to AmTrust by providers from January 1, 2021, through December 31, 2021.

A provider's receipt of an electronic EOR (X12 835) closes the payment loop for a workers’ comp e-bill. Further, an electronic EOR automatically posts to the respective e-bill, thereby significantly reducing a provider's administrative burden of manually recording payment information to the respective e-bill.

For 2021, attached is a CSV list containing 31,514 e-bills providers submitted where AmTrust failed to return a mandated electronic EOR to the provider. The attached CSV list includes the following columns:

• [Bill] Transmission Date: Column L
• EOR (835) Compliance Due Date: Column V
• EOR (835) Receipt Date: Column W - This column is BLANK because AmTrust failed to send daisyBill an electronic EOR (835).
• Patient Name: Column AN
• Claim Number: Column AO

On 4/4/2022, daisyBill emailed the ten (10) AmTrust representatives to report the lack of compliance. A single representative responded, as noted below, and the representative failed to provide any additional information regarding rectifying the AmTrust noncompliance:

XXXXXX Manager, Claims Compliance Operations
“You may use my name as contact for the below, so that we can review and pull in the appropriate parties.”

Per Title 8, California Code of Regulations section 10111.2(b)(10),(11), AmTrust should be subject to audit penalties.

Audit Complaint Details

This Audit Complaint Data submitted to the DWC represents a credible complaint and credible information of claims handling violations.

Bill Transmission: Original Bill / Second Review - 835 EOR Missing

Noncompliance: Claims administrator failed to send an electronic Explanation of Review (EOR) in the mandated ASC X12N/005010X221A1 (835) format, despite the claims administrator sending a 277 Acknowledgement accepting the Original Bill / Second Review Appeal.

DWC Rule 7.1 requires the claims administrator to electronically send an EOR to the provider using the X12 835 EDI standard within 15 working days of the e-bill.

Per California DWC Medical Billing and Payment Guide 7.2, any electronically submitted bill determined to be completed, not paid, or objected to within the 15 working day period, shall be subject to audit penalties per Title 8, California Code of Regulations section 10111.2(b)(10),(11).

daisyBill fights the good fight on behalf of workers’ comp providers. Reach out to see how we can help your practice obtain fast, correct reimbursement for treating injured workers.

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