CA e-EOR Compliance: 2022 Report Card

CA e-EOR Compliance: 2022 Report Card

Not everything in California workers’ comp is complicated.

For example: when a provider chooses to bill electronically for medical services, California regulations require the claims administrator to send the provider an electronic Explanation of Review (e-EOR) with payment (or denial) information. It’s easy to understand the reasons for mandatory e-EORs:

  • e-EORs close the loop on the transaction by automatically posting payment to the e-bill in the provider’s e-billing system. This makes revenue management easy for the practice, vastly reducing the time, person-power, and administrative resources necessary to treat injured workers sustainably.

  • e-EORs offer instantly verifiable proof of timely (or untimely) payment.

When claims administrators fail to return e-EORs, it places an undue administrative burden on the practice, which must manually enter the data from a paper EOR into the e-billing system. Failure to send an e-EOR is a kind of theft of practice resources, including the time and effort that would otherwise be devoted to the care of patients.

As a companion to our 2022 e-bill acceptance report card, below we list the claims administrators that consistently adhered to the e-EOR requirement last year — and the claims administrators that failed to adhere to the requirement in contravention of California regulations.

Meanwhile, in 2022, the Division of Workers’ Compensation (DWC) reportedly went on a record-breaking provider suspension spree. Where is the commensurate concern with enforcement when payers break the rules? It’s nonexistent, allowing claims administrators to game California workers’ comp with impunity.

The irrefutable data below exposes claims administrators’ blatant disregard for payment law, and demonstrates California’s lopsided approach to payer and provider non-compliance.

The Good News: Top CA Claims Admins by e-EOR Compliance

First, the 2022 winners.

In 2022, daisyBill providers submitted 1,571,375 California workers’ compensation medical treatment bills to 295 claims administrators, plus the federal Department of Labor (DOL).

The data below list the 25 top claims administrators that adhered to California’s e-EOR requirement, and returned an e-EOR at least 98% of the time; i.e. these claims administrators failed to return an e-EOR 2% or less of the time in all of 2022.

Claims administrators are listed in ascending order by ‘e-EOR Missing %,’ i.e. the percentage of e-bills for which the claims administrator failed to send an e-EOR. This list includes both large and small claims administrators, proving that all claims administrators are capable of adhering to the e-EOR requirement, 100% of the time.

Note that The Zenith and Sentry Insurance so rarely failed to return an e-EOR in 2022 that, given the volume of e-bills submitted, both claims administrators’ non-compliance rate was statistically 0%. Kudos!

Note also that while California’s State Compensation Insurance Fund (SCIF) maintained a 1% non-compliance rate, the sheer volume of e-bills submitted to SCIF means that SCIF failed to return an e-EOR for over a thousand e-bills — proof that larger claims administrators bear a commensurately greater responsibility to pursue 100% compliance.

Claims Administrator

e-Bill Submission Count

e-EOR Missing Count

e-EOR Missing %

The Zenith

17,545

25

0%

Sentry Insurance

11,730

9

0%

Intact Insurance Specialty Solutions

997

6

1%

Sutter Health

2,434

16

1%

Fresno Unified School District (CA)

1,357

9

1%

Brotherhood Mutual Insurance

429

3

1%

State Compensation Insurance Fund (CA)

107,167

1,006

1%

Alaska National Insurance

5,150

52

1%

Nassco / General Dynamics

2,917

29

1%

Republic Indemnity

10,527

114

1%

Innovative Claim Solutions, Inc.

2,230

27

1%

Elite Claims Management

3,193

42

1%

Mitsui Sumitomo Insurance

1,558

20

1%

GuideOne Insurance

1,931

27

1%

Charles Taylor TPA

1,704

24

1%

Applied Underwriters

1,523

21

1%

Albertsons / Safeway / Vons

5,343

84

2%

Risico Claims Management, Inc.

2,949

50

2%

Tokio Marine Management

649

11

2%

City of San Diego (CA)

5,692

108

2%

City and County of San Francisco (CA)

6,180

122

2%

County of Santa Clara (CA)

5,200

103

2%

CNA Insurance

6,023

126

2%

County of San Diego (CA)

4,501

100

2%

Maine Employers Mutual Indemnity Company

168

4

2%

The Bad News: Bottom CA Claims Admin by e-EOR Compliance

And now, the (long) list of 2022 losers.

The data below list the 78 claims administrators that failed to adhere to California’s e-EOR requirement (some much more consistently than others). The companies on this list failed to return at least 100 e-EORs in 2022, and the count of missing e-EORs represented more than 2% of the e-bill volume sent to the claims administrator.

Claims administrators with a non-compliance rate of 10% or greater are bolded.

In total, these claims administrators received 1,210,757 e-bills from daisyBill providers, and failed to return 180,958 e-EORs — a collective 15% non-compliance rate. The administrative cost incurred by providers can be calculated under the following assumptions:

  • It takes roughly 2 minutes to post a paper EOR (receive and open envelope, locate e-bill in billing system, manually post the payment information, upload the paper EOR to the billing system).
  • Multiply 2 minutes by 180,958 missing e-EORs; that’s 361,916 minutes wasted to post paper EORs.
  • Divide 361,916 minutes by 60 minutes; that’s 6,032 administrative hours wasted, simply to work around the non-compliance of 78 claims administrators.

The above analysis of provider administrative costs assumes these claims administrators actually sent a paper EOR, rather than simply ignoring the bill — not always a safe assumption.

Two honorable mentions:

  • AmTrust North America closed 2022 with an overall non-compliance rate of 48.1% — not pretty. However, that reflects an incredible turnaround over the course of the year. AmTrust failed to return e-EORs 99.5% of the time in January, but by December AmTrust’s non-compliance rate plummeted to just 4%.
  • Berkshire Hathaway also made significant strides, from a January non-compliance rate of 40.3% to a low of 2.3% in July, before relapsing to a December rate of 17.3%.

Coming in first (or really, dead last): Sedgwick Claims Management Services, the largest claims administrator by bill volume — and one of the most notoriously non-compliant companies ever to saddle California providers with unwarranted, costly payment friction.

In 2022, Sedgwick received over 61,000 e-bills from California providers that Sedgwick either failed to pay, or non-compliantly answered with a paper EOR.

Claims Administrator

e-Bill Submission Count

e-EOR Missing Count

e-EOR Missing %

Sedgwick Claims Management Services

289,481

61,588

21%

AmTrust North America

36,156

17,406

48%

Berkshire Hathaway Homestate Companies

66,119

11,302

17%

ESIS, Inc.

50,038

10,641

21%

Liberty Mutual Insurance

50,323

5,032

10%

Cannon Cochran Management Services Inc.

30,544

4,939

16%

Employers Compensation Insurance Company

15,406

3,942

26%

Tristar Risk Management

36,144

3,875

11%

Gallagher Bassett

93,807

3,682

4%

Matrix Absence Management

3,342

3,261

98%

Los Angeles County Metropolitan Transit Authority (CA)

18,475

3,158

17%

AIG Claims, Inc.

8,191

2,788

34%

Broadspire

36,806

2,689

7%

CorVel

52,693

2,645

5%

County of San Bernardino (CA)

2,655

2,618

99%

Marriott Claims Service Corp

6,131

2,444

40%

Athens Administrators

31,742

2,413

8%

Guard Insurance Group

6,574

1,962

30%

Keenan & Associates

22,441

1,898

9%

LWP Claims Solutions

12,719

1,835

14%

Zurich Insurance North America

53,884

1,663

3%

Department of Labor

21,401

1,655

8%

Intercare Holdings Insurance, Inc.

54,574

1,651

3%

Strategic Comp

3,610

1,626

45%

Helmsman Management Services

14,601

1,610

11%

American Claims Management, Inc

7,055

1,516

22%

Church Mutual Insurance Company

1,852

1,493

81%

Next Level Administrators

13,112

1,344

10%

Chubb Group of Insurance Companies

10,804

1,242

12%

CompWest Insurance Company

10,003

1,232

12%

California Insurance Guarantee Association

3,506

1,222

35%

Adminsure, Inc.

19,756

988

5%

Acclamation Insurance Management Services

14,401

965

7%

Creative Risk Solutions

1,037

875

84%

Allianz

2,549

795

31%

Pacific Compensation Insurance Company

12,609

660

5%

Association of California Water Agencies JPIA

685

535

78%

Sempra Energy Employee Care Services

2,812

501

18%

Benchmark Insurance Company

8,162

431

5%

Enstar Group

3,578

425

12%

City of Burbank (CA)

437

419

96%

AmeriTrust Group, Inc.

3,851

418

11%

Loma Linda University (CA)

394

390

99%

City of Los Angeles (CA)

7,698

376

5%

Garden Grove Unified School District (CA)

1,619

365

23%

City of Anaheim (CA)

422

364

86%

Preferred Employers Insurance Company

8,307

353

4%

Barrett Business Services Inc.

5,900

330

6%

Trindel Insurance Fund

337

327

97%

National Interstate Insurance

1,822

309

17%

City of Riverside (CA)

314

305

97%

Hazelrigg Claims Management Services

611

304

50%

Beta Healthcare Group Risk Management Authority

4,501

293

7%

Sierra Pacific Industries

257

255

99%

Markel First Comp Insurance

2,740

253

9%

Cottingham & Butler Claim Services, Inc.

3,051

233

8%

National Liability and Fire Insurance Company

904

227

25%

City of Los Angeles Department of Water and Power (CA)

2,338

207

9%

Farmers Insurance

7,834

202

3%

City of Torrance (CA)

620

192

31%

Municipal Pooling Authority (CA)

713

174

24%

Berkley Net Underwriters, LLC

1,593

147

9%

WCF Insurance

1,946

144

7%

Midwest Insurance

2,969

143

5%

Arrowpoint Capital

165

138

84%

Murphy and Beane

516

136

26%

SafeCo Insurance

176

135

77%

Self-Insured Schools of California (CA)

2,190

132

6%

Omaha National Group

5,069

132

3%

City of Compton (CA)

130

128

99%

Pacific Gas & Electric

1,749

118

7%

City of Long Beach (CA)

672

116

17%

Crum & Forster

3,029

114

4%

Great West Casualty Company

111

111

100%

Contra Costa County Schools Insurance Group (CA)

1,189

110

9%

United Heartland

1,229

108

9%

Care West Insurance Company

1,235

102

8%

Protective Insurance

2,341

101

4%

Totals

1,210,757

180,958

15%

The data above produces the same conclusion as our recently released data on e-bill acceptance. If some providers are slow to embrace e-billing for workers’ comp, it’s not because they enjoy wasting time and resources on analog revenue management. It’s arguably because California is not doing enough to ensure that if providers play ball, claims administrators will too.

Provider fraud and other crimes are clearly not tolerated; the DWC suspended more providers in 2022 than in any year since 2017. Yet this 15%+ payer non-compliance rate stands.

California legislators and regulators, this is what’s holding back the statewide transition to faster, more efficient statewide e-billing. Employers, this is how your workers’ comp premiums are being wasted. Injured workers, this is what’s driving providers from the system and making it unnecessarily difficult to find care.


daisyBill tracks responses to your bills, appeals, and RFAs — so your practice knows when payers break the rules. Click below to learn more, or request a demonstration.

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