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.


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