Data! Top 10 Claims Admins: CA Electronic EOR Compliance

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.


Protect your practice revenue. Harness the power of daisyBill software, data, and expertise for faster, better workers’ comp billing.

GET IN TOUCH

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.