Data! Top 10 Claims Admins: CA Electronic EOR Compliance
Electronic Explanations of Review (e-EORs) are a non-negotiable requirement of workers’ comp electronic billing. Within 15 working days of receiving a provider’s e-bill, the claims administrator must — by California law — return the e-EOR. This allows billing software to automatically post payment details to the e-bill and closes the electronic loop on the transaction.
daisyBill closely monitors claims administrator compliance with e-EOR requirements, as they are crucial to our provider clients’ revenue management. Without e-EORs, billing software cannot automatically record payment information for e-bills, and providers are forced to waste practice time and resources updating their e-bills manually.
Below, see how our top 10 claims administrators by bill volume complied with sending electronic EORs (in the mandated X12 835 format) in 2022 so far.
Fully Compliant e-EORs
Data from daisyBill shows exactly how often each of our top 10 claims administrators timely returned a compliant, valid X12 835 e-EOR.
All tables below reflect e-EOR data for e-bills submitted from January 1, 2022 to August 31, 2022 by daisyBill clients.
Claims Administrator |
e-Bills Sent to Claims Administrator by daisyBill |
% of Total e-Bills Sent by daisyBill |
e-EOR Compliant Count |
Compliance Rate |
Sedgwick Claims Management Services |
192,799 |
18% |
109,290 |
57% |
State Compensation Insurance Fund (CA) |
72,206 |
7% |
50,131 |
69% |
Gallagher Bassett |
62,586 |
6% |
49,625 |
79% |
Berkshire Hathaway Homestate Companies |
43,428 |
4% |
26,428 |
61% |
Zurich Insurance North America |
36,822 |
3% |
20,650 |
56% |
Liberty Mutual Insurance |
34,150 |
3% |
28,635 |
84% |
ESIS, Inc. |
33,678 |
3% |
14,339 |
43% |
CorVel |
31,662 |
3% |
23,026 |
73% |
Intercare Holdings Insurance, Inc. |
31,302 |
3% |
15,652 |
50% |
Tristar Risk Management |
29,440 |
3% |
13,379 |
45% |
Most Compliant: Liberty Mutual
Liberty Mutual timely returned compliant e-EORs for 28,635 out of 34,150 e-bills, for a compliance rate of 84%. The sixth-largest recipient of daisyBill e-bills, Liberty Mutual gave the best performance overall by percentage.
However, Liberty Mutual has work to do. Compliance with legal requirements should be 100%; 83% is (barely) a grade B effort. Further below, the data show that to receive a grade of ‘A,’ Liberty Mutual must correct its missing e-EORs.
Least Compliant: ESIS, Inc.
In last place is Third-Party Administrator (TPA) ESIS, Inc., which returned timely, compliant e-EORs for only 14,339 e-bills out of 33,678 submitted — less than half, for a dismal e-EOR compliance rate of just 43%. Grade: F-
Untimely e-EORs
As mentioned above, within 15 working days of receipt of an e-bill, California regulations require claims administrators to send an e-EOR in response (14 calendar days to send the e-EOR for Second Review appeals). Below, daisyBill data shows how well (or not) claims administrators complied with e-EOR timeliness requirements.
Claims Administrator |
e-Bills Sent to Claims Administrator |
% of Total e-Bills Sent by daisyBill |
e-EOR LATE Count |
Non-Compliance Rate |
Sedgwick Claims Management Services |
192,799 |
18% |
29,508 |
15% |
State Compensation Insurance Fund (CA) |
72,206 |
7% |
19,925 |
28% |
Gallagher Bassett |
62,586 |
6% |
3,072 |
5% |
Berkshire Hathaway Homestate Companies |
43,428 |
4% |
3,128 |
7% |
Zurich Insurance North America |
36,822 |
3% |
5,886 |
16% |
Liberty Mutual Insurance |
34,150 |
3% |
269 |
1% |
ESIS, Inc. |
33,678 |
3% |
2,492 |
7% |
CorVel |
31,662 |
3% |
5,727 |
18% |
Intercare Holdings Insurance, Inc. |
31,302 |
3% |
11,017 |
35% |
Tristar Risk Management |
29,440 |
3% |
1,265 |
4% |
Most Compliant: Liberty Mutual
Liberty Mutual takes the cake again, returning untimely e-EORs for only 1% of daisyBill providers’ e-bills. Good job, Liberty Mutual!
Least Compliant: Intercare Holdings Insurance, Inc.
Intercare was late returning e-EORs for 11,017 e-bills out of 31,302 submitted. That’s a non-compliance rate of 35%, showing that while Intercare eventually returns e-EORs (Intercare’s rate of missing e-EORs was only 5%), the TPA takes its sweet time.
Missing e-EORs
Sometimes, the provider receives no e-EOR at all. This means either 1) the claims administrator did not pay the bill, or 2) the claims administrator sent a non-compliant paper EOR, forcing the provider to manually post the EOR data to their e-billing software. Either way: not acceptable.
Claims Administrator |
e-Bills Sent to Claims Administrator |
% of Total e-Bills Sent by daisyBill |
e-EOR MISSING Count |
Non-Compliance Rate |
Sedgwick Claims Management Services |
192,799 |
18% |
43,891 |
23% |
State Compensation Insurance Fund (CA) |
72,206 |
7% |
319 |
0% |
Gallagher Bassett |
62,586 |
6% |
2,036 |
3% |
Berkshire Hathaway Homestate Companies |
43,428 |
4% |
9,114 |
21% |
Zurich Insurance North America |
36,822 |
3% |
1,237 |
3% |
Liberty Mutual Insurance |
34,150 |
3% |
3,693 |
11% |
ESIS, Inc. |
33,678 |
3% |
10,976 |
33% |
CorVel |
31,662 |
3% |
1,736 |
5% |
Intercare Holdings Insurance, Inc. |
31,302 |
3% |
1,473 |
5% |
Tristar Risk Management |
29,440 |
3% |
2,663 |
9% |
Most Compliant: State Compensation Insurance Fund (SCIF)
SCIF is the second-largest recipient of daisyBill e-bills, having received 72,206 e-bills from our providers from January through August of this year. Of those, SCIF failed to return an e-EOR for 319. If SCIF repaired its untimely e-EORs (SCIF has blamed Anthem for its own non-compliance), SCIF would earn a solid A+ for e-EORs.
Least Complaint: ESIS, Inc.
Out of 33,678 e-bills submitted, ESIS failed to return an e-EOR for 10,976, or 33%. This is, by any reasonable standard of compliance, unacceptable. Having hounded ESIS across California to pay Medical-Legal bills, we shouldn’t be surprised to see the TPA disregard medical bill requirements. Any employer considering ESIS as a TPA would serve themselves well by reviewing this EOR data.
Sedgwick’s e-EOR Problem
Sedgwick Claims Management Services is by far the most-daisyBilled claims administrator by bill volume; our providers sent the TPA almost 200,000 e-bills from January 1 to August 31. While Segwick didn’t earn the distinction of “least compliant” for any of the specific categories above, its overall non-compliance is a serious issue
|
Sedgwick 835 Compliance Description |
Count of Submissions |
Percent of Total |
835 Compliant |
109,290 |
57% |
835 Late |
29,508 |
15% |
835 Missing |
43,891 |
23% |
835 Invalid Data |
1,907 |
1% |
835 N/A (277 Reject) |
5,672 |
3% |
835 N/A (Non-EDI) |
386 |
0% |
835 Pending |
2,145 |
1% |
Totals |
192,799 |
100% |
Most distressingly, Sedgwick returned zero e-EORs whatsoever for 23% of the e-bills submitted by our providers. That’s the second-worst rate after ESIS — but Sedgwick is processing many, many more e-bills. By way of comparison:
- ESIS failed at a rate of 33%, meaning no e-EOR was returned for 10,976 e-bills.
- Sedgwick failed at a rate of 23%, meaning no e-EOR was returned for 43,891 bills (!) in the same time frame.
The benefits of e-billing should not flow in only one direction. Anything less than 100% compliance with e-EOR requirements means that providers — and by extension, injured workers and employers — are being mistreated.
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DaisyBill provides content as an insightful service to its readers and clients. It does not offer legal advice and cannot guarantee the accuracy or suitability of its content for a particular purpose.
