Using data generated by over 18,000 bills sent by our provider clients in 2022 to Athens Administrators, daisyBill demonstrates consistent non-compliance with California e-billing regulations by this Third-Party Administrator (TPA).
For bills submitted in 2022, below is the message and formal Audit Complaints daisyBill submitted to the Division of Workers’ Compensation (DWC), outlining Athens’ systemic non-compliance, specifically the TPA’s failure to accept 5,985 electronic bill submissions (33% of the bills sent to Athens through daisyBill) in the mandated X12 837 format.
As advocates for providers, we remind readers that if a provider fails to timely or accurately submit a workers’ comp bill for any reason, the claims administrator simply denies the bill as invalid, and refuses payment as permitted by California law. The provider has little recourse to correct the alleged non-compliance, resulting in forfeiture of reimbursement for treatment rendered.
We urge the DWC to enforce California workers’ comp billing and payment requirements by imposing appropriate consequences on Athens for its consistent failure to comply with California law. Athens’ actions impose an unnecessary administrative burden on providers who agree to treat California’s injured workers.
Subject: Athens EDI Non-compliance: X12 837 e-Bill Not Accepted - Count 5,985
Below is an Audit Complaint reporting credible data that Athens Administrators ignores California law by failing to accept bills electronically in the X12 837 format.
Since the acceptance of e-bills was mandated in California, Athens has restricted its acceptance of e-bills to a selected list of the clients for which it acts as Third-Party Administrator (TPA).
Athens’ refusal to accept e-bills for all of its TPA clients directly violates California law and inflicts a significant burden on California providers. More importantly, e-billing is not viable when a claims administrator can selectively choose to adhere to California law.
For bills submitted by daisyBill clients January 1, 2022 through July 31, 2022, Athens failed to accept e-bills (X12 837) from daisyBill providers as mandated by California law for 5,985 (33%) submissions
Further, below are screenshots of the complexities a provider must navigate to manage Athens’ refusal to use a single Payer ID for all of its TPA clients.
To send an e-bill to Athens, the provider must select the correct underlying payer name so that daisyBill can route the e-bill to the correct Athens Payer identification number.
If the provider fails to locate the name of the underlying payer in the Athens payer list, the provider selects that the payer is ‘Not Listed’ and daisyBill faxes a paper bill directly to Athens.
This Audit Complaint data represents California workers’ comp bills submitted to Athens by daisyBill providers from January 1, 2022 through July 31, 2022.
Attached is a CSV list containing 5,985 bills daisyBill providers submitted to Athens where Athens failed to accept the bill electronically in the X12 837 format. The attached CSV list includes the following columns:
This Audit Complaint Data submitted to the DWC represents a credible complaint and credible information of claims handling violations.
Noncompliance: Claims administrator failed to accept an Original Bill or Second Review Appeal in the mandated ASC X12N/005010X222A1 837 format.
Effective October 2012, DWC Rule 7.1 requires the claims administrator to accept workers’ comp e-bills from providers in the X12 837 format.
CCR §10106.1(c)(3) instructs that the Audit Unit “shall review and compile complaints” that indicate a claims administrator is “failing to meet their obligations under Divisions 1 or 4 of the Labor Code or regulations of the Administrative Director.”
Pursuant to LAB §129, CCR §10106.1(c)(3) provides the DWC Audit Unit may target audit subjects based on: “...credible complaints and/or information received by the Division of Workers' Compensation that indicate possible claims handling violations, except that the Audit Unit will not target audit subjects based only on anonymous complaints unless the complaint(s) is supported by credible documentation.
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