California claims administrators have certain responsibilities when it comes to processing bills. They must issue timely and complete Explanations of Review (EORs) and payments, both for original bills and second reviews. And, ever since October 2012, California Labor Code requires claims administrators to accept electronic billing for workers’ compensation bills.

But the fact that these rules exist, doesn’t guarantee that the rules are always followed. Every month, we hear hundreds of stories from providers across the state alleging noncompliant behavior on the part of claims administrators. It’s a frustrating fact of the system. Fortunately, providers have a recourse: Filing an Audit Complaint.*

DaisyBill’s Revenue Cycle Management software includes an Audit Complaint submission tool that thoroughly documents claims administrators’ failures to fulfill their compensation obligations. Submitting an audit complaint is easy – it takes our clients about five seconds – and the resulting data points help us detect and track patterns of claims administrator non-compliance.

To crystallize our data, we created five distinct complaint categories and reasons:

• Processing Overdue
• Penalty and Interest Due
• EOR Non-Compliant
• Denial Incorrect
• e-Billing Non-compliant

From these categories, a portrait of the most problematic claims administrator behavior begins to emerge. The five most common reasons for Audit Complaints submitted by our clients reveal that some claims administrators face persistent problems issuing EORs and acknowledging the receipt of electronic bills.

It’s important to acknowledge that the numbers below represent only a fraction of the bills we process. It’s equally important to acknowledge that claims administrators should not be having these problems in 2016.

The lack of response to electronically transmitted Original Bills is particularly irksome. Every bill submitted through DaisyBill receives electronic confirmation of claims administrator receipt, so we are certain that the claims administrators received the bills in question. Electronic bills submitted through our software simply do not get lost in the ‘electronic’ mail.

Stay tuned for a series of detailed analyses of each of the audit complaint reasons above. In the meantime, we strongly encourage you to submit Audit Complaints everytime you encounter non-compliant behavior in a claims administrator. If you aren’t a DaisyBill customer, you can find Audit Complaint forms and directions for manual filing on the DWC Audit Unit website.

To make things easier for you, we provide an online library of suggested Audit Complaint language. A few minutes of copying and pasting could lead to the DWC intervening and correcting a claims administrator’s non-compliance. You can file anonymously, so reporting improper behavior poses no risk to your relationship with the claims administrator in question.

Filing an Audit Complaint is a no-lose proposition. At best, it could lead to DWC intervention. At worst, it gives the DWC valuable data and serves as a quick, simple way to affect change. Each time you file, you’re making the system a little better of all of us – and we thank you for that.

*NOTE: The Audit Complaint form was updated in 2019. Access the updated form here: https://www.dir.ca.gov/dwc/Auditref.pdf

To learn more about Audit Complaints, including a thorough discussion of our sample templates, watch our Audit Complaint webinar.

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