CA: West Bend Insurance's EOR Non-Compliance
West Bend Insurance Company (WBIC) is not among the largest payers in our systems, handling less than 500 of our providers’ bills annually. That doesn’t exempt it from complying with California workers’ comp payment laws and regulations.
WBIC recently:
- Failed to timely respond to a California provider’s electronic bill (e-bill),
- Responded to an e-bill with an electronic Explanation of Review (e-EOR) that failed to provide a substantive payment denial reason, and
- Provided a paper EOR that is a masterclass in non-compliance, with the majority of the required information missing.
Providers need complete, compliant EORs (electronic or paper) to manage revenue efficiently and respond to denials and reductions in a timely manner. Without those EORs, treating injured workers becomes even more administratively difficult than it already is (and that’s saying something).
On top of failing to send a useful e-EOR, WBIC’s paper EOR (shown below) shows either disregard for state law or a troubling lack of knowledge thereof.
Of course, payer non-compliance this egregious is not unexpected in California workers’ comp, as the agency responsible for enforcing the rules, the California Division of Workers’ Compensation (CA DWC), has been largely ineffectual at enforcing payment laws and regulations.
WBIC’s Vague Denial Codes
Initially, WBIC completely ignored the provider’s original bill, sending no response by the 15-day legal deadline for e-bills. Accordingly, daisyCollect resubmitted the e-bill. Upon resubmission, WBIC responded with an e-EOR denying payment.
California Labor Code requires all EORs to include “The basis for any adjustment, change, or denial of the item or procedure billed.” WBIC’s e-EOR technically listed an official Claim Adjustment Reason Code (CARC) and Remittance Advice Remark Code (RARC)…but both are so vague as to be functionally meaningless:
- CARC P12: “Workers’ compensation jurisdictional fee schedule adjustment”
- RARC N600: “Adjusted based on the applicable fee schedule for the region in which the service was rendered”
These are generic codes that offer no specific reason for the denial; they simply invoke the fee schedule without indicating how the bill supposedly doesn’t align with it. Accordingly, daisyCollect contacted WBIC for an explanation.
A WBIC rep informed our agent that WBIC had actually paid the bill, rendering the e-EOR inaccurate.
One Inc. Offers Laughably Non-Compliant EOR
To retrieve the payment EOR required accessing the abysmal and ill-functioning One Inc. payment portal. The EOR we found there (below) beggars belief in its absolute inadequacy as a remittance advice document.
WBIC: 22 Violations on One EOR
The CA DWC’s Medical Billing and Payment Guide (MBPG) includes detailed instructions on the required elements of an EOR in its Table 3.0. Nearly every required element is missing from the so-called EOR above, making this document functionally useless.
Among many other deficiencies, it’s practically impossible to match this EOR to any particular bill, as it’s missing the charge amount, procedure codes, and patient control number used to identify the specific claim (and those are just the first problems we noticed).
The table below outlines every required element of an EOR that this embarrassment of a document is missing, per the MBPG. In total, the EOR is deficient in 22 separate elements.
Legal and regulatory EOR requirements exist for a reason.
Providers cannot manage revenue efficiently if payers don’t shoulder their part of the administrative workload. Non-compliance at this level is indefensible, but it’s also predictable given the CA DWC’s persistent failure to take real enforcement action when payers break the rules.
MBPG Field Description |
MBPG Rule (Required/ Situational) |
Requirement |
Deficiency |
Date of Review |
R |
The date the payer completed its bill review is a required element, distinct from the payment date. |
A "Issued Date" (03/16/2026) and a "Paid Date" (03/16/2026) appear, but no discrete Date of Review is populated. |
Method of Payment |
S |
Since a payment was issued, the EOR must indicate whether payment was by paper check or EFT. |
Not stated anywhere on the document. |
Payment ID Number |
S |
If a payment is made, the check number or EFT Tracer Number must be identified. |
A "Payment Number" header field appears on the form but it is not identified as a check number or EFT Tracer Number. The "Payment Id" numbers listed are not identified as check numbers or EFT tracers, and it is unclear whether they correspond to this required element at all. |
Payer Address |
R |
Payer Address is a required data element. |
Only "West Bend Insurance Company" is listed. No street address, city, state, or zip is provided anywhere on the document. |
Pay-To Provider Address |
R |
The address of the Pay-To Provider is required. |
No provider address is shown; only the payee name appears. |
Pay-To Provider TIN |
R |
Pay-To Provider Tax Identification Number is a required element. |
No TIN/FEIN is present for the provider. |
Patient Social Security Number |
R |
Patient SSN is a required identifying data element. |
No SSN is present for the injured worker. |
Employer ID |
R |
Employer ID assigned by the payer is required. |
"Insured Name" (MAINS'L California, LLC) is shown, but no corresponding Employer ID is provided. |
Rendering Provider ID |
R |
Rendering Provider ID (NPI Number) is required on every EOR. |
No NPI is disclosed for the rendering provider. |
PPO/MPN Name |
S |
If a PPO/MPN contract rate was applied, the PPO/MPN name and ID must be disclosed, and any adjustment must be explained with a reason code. |
No PPO/MPN is identified. The document provides no basis to confirm whether the payment amount reflects the correct contracted or fee-scheduled rate. |
PPO/MPN ID Number |
S |
If a PPO/MPN contract rate was applied, the PPO/MPN name and ID must be disclosed, and any adjustment must be explained with a reason code. |
No PPO/MPN ID is identified. |
Bill Submitter’s Identifier |
R |
The bill’s unique identification number must be identifiable. |
"Invoice/Account #" and "Payment Id" appear, but the document does not label which number, if any, corresponds to the provider’s Bill Submitter’s Identifier versus the Payer Bill ID Number. |
Payment Status Code |
R |
Must indicate Paid (1), Denied (4), or Reversal of Previous Payment (22). |
The payment amount implies Payment Status Code 1 for “Paid,” but no Status Code is present. |
Total Charges |
R |
The total billed charge amount is a required element, necessary to confirm whether the payment equals, exceeds, or reduces the billed amount. |
No billed/charge amount appears anywhere on the document, only the paid amount ($2,107 per line, $4,214 total). Without the charge amount, the provider cannot identify the specific bill or verify the payment reflects the correct fee schedule or contract rate. |
Payer Bill ID Number |
R |
The payer/bill-review entity’s tracking number must be identifiable. |
"Invoice/Account #" and "Payment Id" appear, but the document does not label which number, if any, corresponds to the provider’s Bill Submitter’s Identifier versus the Payer Bill ID Number. |
Date Bill Received |
R |
The date the payer received the bill is required so the provider can confirm the statutory 15-working day payment and EOR-issuance deadlines were met. |
No Date Bill Received is disclosed anywhere on the document. Without it, timeliness of the 03/16/2026 payment cannot be verified, and any late-payment penalty or interest owed under Labor Code §4603.2 cannot be calculated. |
DWC Bill Adjustment Reason Code(s) and DWC Explanatory Message(s) |
S |
Required whenever an adjustment is made to the bill, billed charges are denied, or any explanatory message needs to be communicated to the provider. |
No DWC Bill Adjustment Reason Codes or Explanatory Messages appear on the document at all. Because Total Charges (Item 32) is also missing, it cannot be determined whether the $2,107 payments equal the billed amount or reflect an undisclosed reduction. If any reduction occurred, the complete absence of adjustment codes is non-compliant. |
Paid Procedure Code |
R |
Each service line must identify the specific CPT/HCPCS/revenue code billed. |
No procedure codes are shown for either service line. The document identifies only a generic "Medical Bill Payment" description and a service-period date range. It is impossible to determine what specific services were billed or paid. |
Charge Amount |
R |
Each service line must identify the charge amount for the code(s) billed |
No charge amounts are shown for either service line. The document identifies only a generic "Medical Bill Payment" description and a service-period date range. It is impossible to determine what specific services were billed or paid. |
Paid Units |
R |
Each service line must identify the paid unit(s) |
No unit counts are shown for either service line. The document identifies only a generic "Medical Bill Payment" description and a service-period date range. It is impossible to determine what specific services were billed or paid. |
DWC Service Level Adjustment Reason Code(s) and DWC Explanatory Message(s) |
S |
Required whenever an adjustment is made to the bill, billed charges are denied, or any explanatory message needs to be communicated to the provider. |
No DWC Bill Adjustment Reason Codes or Explanatory Messages appear on the document at all. Because Total Charges (Item 32) is also missing, it cannot be determined whether the $2,107 payments equal the billed amount or reflect an undisclosed reduction. If any reduction occurred, the complete absence of adjustment codes is non-compliant. |
Notification of Provider Remedies |
R |
Every EOR must contain the mandated "TIME LIMITS TO DISPUTE PAYMENT AMOUNT" language, notifying the provider of its right to request Second Review within 90 days of service of the EOR, and the subsequent Independent Bill Review (IBR) remedy. |
This mandatory statutory notice is entirely absent from the document. The provider is given no notice whatsoever of its right to seek Second Review or IBR, or of the 90-day deadline, jeopardizing the provider’s ability to timely preserve dispute rights. |
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is there anything we can do on these payers that just simply do not pay? I have been getting so much from Gallagher Basset, Sedgwick, Athens... Upon research, it only points out to filing a claim with workers comp board of California but I feel that is another dead end. I feel like these companies are getting away with so much and maybe they're hoping that we would just "let it go" because it is too time consuming to fight to get the visits paid.