California mandates that all (repeat: all) workers’ comp claims administrators accept electronic bills from providers and respond to those e-bills with electronic Explanations of Review (e-EORs).

Put simply, e-billing isn’t e-billing without e-EORs.

When claims administrators remit e-EORs, the payment information and data automatically post to the provider’s billing system, saving the practice significant time and manual work that would otherwise be required to post paper EOR details to each bill.

Most importantly, e-EORs close the payment loop and allow providers to ascertain which claims administrators fail to process bills quickly and compliantly.

Below, we share daisyData from the first four months of 2024, revealing which claims administrators complied most consistently with the e-EOR mandate. We also share which claims administrators were non-compliant to the point of warranting intervention from the California Division of Workers’ Compensation (DWC).

Of course, we’re not holding our breath in anticipation of DWC enforcement. The more challenging these claims administrators make managing workers’ comp payments, the easier it is for them to siphon off provider revenue. And as readers know, the state of California isn’t known for standing in the way of claims administrators’ profit.

Hat Tip: Most Compliant Claims Admins Jan-April 2024

All the tables in this article reflect claims administrators to which daisyBill providers sent at least 1,000 bills between January 1, 2024 and April 30, 2024.

Let’s start with the winners (though providers and injured workers are the true winners when claims administrators follow the law).

The standouts are Sentry Insurance and Sempra Energy Employee Care Services. In the first four months of 2024, Sentry sent an e-EOR for all but 2 e-bills, while Sempra failed to remit an e-EOR only once. To nick a sentiment from Tina Turner, Sentry and Sempra are simply the best.

Honorable mention goes to Travelers, Employers, and the Department of Labor, all of which maintained a statistical ‘e-EOR Missing Total’ of 0%. Congratulations and thank you!

Get It Together: Least Compliant Claims Admins

Let’s be clear: responding to e-bills with e-EORs isn’t some act of charity or even courtesy by a claims administrator. It’s a requirement in California. 

The data below reveal that Tristar Risk Management was the worst e-EOR offender. Tristar’s 84% non-compliance rate is a slap in the face of providers and injured workers statewide. This TPA can make all the irrelevant and unacceptable excuses it wants; nothing makes its behavior defensible.

Then there’s Sedgwick, which abused the highest number of providers by failing to deliver over 23,700 e-EORs.

All claims administrators below failed to remit e-EORs for at least 18% of the e-bills providers sent. This lack of compliance represents thousands of e-bills that the claims administrator either did not pay or forced the provider to expend significant time and administrative resources to record payment information from a paper EOR.

By failing to follow the law at such unbelievably high rates, the claims administrators above are making it harder for doctors to treat injured workers—and shining a glaring spotlight on the impotence of the DWC.

As a reminder, daisyBill has submitted over 190,000 Audit Complaints to the DWC reporting Sedgwick’s rampant e-EOR non-compliance to no effect. In their recalcitrance, Sedgwick is the standard-bearer of the impunity at the heart of California’s workers’ comp system’s dysfunction.

Top 10 Claims Admin by Bill Count

Below are the ten claims administrators to which daisyBill clients sent the most bills between January 1, 2024 and April 30, 2024, in descending order of bill volume.

Two of the claims admins listed below are also on the “Most Compliant” list above. Travelers processed nearly 15,000 e-bills and failed to send an e-EOR only 34 times. State Compensation Insurance Fund processed over 40,000 e-bills and still maintained a mere 1% non-compliance rate.

We salute Travelers and State Comp. Well done.

Only one claims admin listed below is also on the “Least Compliant” list: perennial villain Sedgwick Claims Management Services, Inc., with an 18% non-compliance rate.

For more detailed daisyData and analytics on claims administrator compliance, see our Claims Administrator Directory.

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.

LEARN MORE