California workers’ comp has many complex rules — but one rule is pretty simple. When a provider transmits their workers’ comp bills electronically (e-bills), the claims administrator is legally required to send the provider an Explanation of Review electronically (e-EOR).

e-EORs instantly verify and timestamp payment and automatically post payment to the bills in the provider’s e-billing system. e-EORs vastly reduce the time, person-power, and administrative resources necessary to treat injured workers sustainably.

When claims administrators fail to return e-EORs, it places an extra, unnecessary administrative burden on providers, because administrative staff must manually enter the data from paper EORs into the e-billing system. Paper EORs siphon practice resources better spent on the already heavy administrative burdens of workers’ comp.

Below we share data on claims administrators that failed to send e-EORs in response to e-bills submitted by daisyBill providers from January 1, 2023 to May 31, 2023.

It will come as no surprise that some claims administrators ignore the law with the kind of impunity that could only result from the double-sided regulatory enforcement that defines California workers’ comp.

Worst of the Worst: Most Non-Compliant Claims Admins

The Grand Champion of e-EOR scofflawery so far this year: the County of San Bernardino, a self-insured public employer that maintained a solid 100% non-compliance rate. For 5 months in a row, San Bernardino remitted exactly zero e-EORs to providers. Whisky Tango Foxtrot, San B.

e-EOR Compliance January-May 2023

The 39 claims administrators below are listed in descending order of the number of e-bills for which no e-EOR was remitted. These insurers, employers, and Third-Party Administrators (TPAs) varied in their compliance rates, but all failed to remit e-EORs for at least 5% of e-bills submitted by daisyBill providers.

Of particular note is Sedgwick Claims Management Services, Inc., a TPA that, in our view, has repeatedly demonstrated itself to view California regulations as gentle suggestions, rather than hard rules to be followed.

The largest claims administrator by volume in our system, Sedgwick failed to remit e-EORs for 28,828 e-bills in the first 5 months of this year, far more than any other claims administrator.

Sedgwick’s 22% non-compliance rate indicates that for 28,828 e-bills, Sedgwick either didn’t pay the provider, or forced the provider to waste administrative time and resources posting payments the old-fashioned way — in contravention of both the law and the entire purpose of e-billing.

California regulators and legislators, we urge you to study the data above, and act accordingly.

We at daisyBill are using our data to ensure that non-compliance isn’t practiced in the dark — your job is to ensure it isn’t practiced without consequences.

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