ESIS: 10 Audit Complaints Filed With CA DWC

ESIS: 10 Audit Complaints Filed With CA DWC

California law requires claims administrators to send an Explanation of Review (EOR) and payment to the physician within 60 days of receiving a bill for Medical-Legal services. However, in 10 separate cases, ESIS failed to meet this requirement — despite repeated outreach from daisyBill.

Failing to respond to bills places a significant, unwarranted strain on Qualified Medical Evaluators (QME) and Agreed Medical Evaluators (AME), who must expend significant practice resources to pursue reimbursement. As such, daisyBill filed 10 formal Audit Complaints with the Division of Workers’ Compensation (DWC) on behalf of our physician clients.

Below, see our message to the DWC.

To: XXXXXXXX@dir.ca.gov

Subject: ESIS - Medical-Legal Payments Missing


Hello XXXXXXXX,                                

Below is an Audit Complaint reporting that ESIS, Inc. failed to timely reimburse providers for Medical-Legal bills. This Audit Complaint data represents California workers’ comp Medical-Legal bills submitted to ESIS as follows:

10 bills submitted 9/8/2021 - 5/26/2022

California Code of Regulations Section 9794(b) requires claims administrators to reimburse providers for Medical-Legal expenses within 60 days after receipt of bill and supporting documents.

Rather than compliantly processing providers’ bills and sending providers the mandated explanations of review with payment or a reason for denial, ESIS refuses to process providers’ Medical-Legal bills. Further, ESIS adjusters and supervisors refuse to return phone call inquiries regarding payment status.

Attached is credible data representing that ESIS systematically failed to compliantly process providers’ Medical-Legal bills.

This Audit Complaint data represents California workers’ comp Medical-Legal bills submitted to ESIS by providers from September 2021 through May 2022.

Attached is a CSV list containing 10 Medical-Legal bills providers submitted where ESIS failed to remit payment within the mandated 60 calendar days. The attached CSV list includes the following columns:

  • [Bill] Submission Date: Column F
  • EOR Compliance Due Date: Column G - Penalty and Interest are owed
  • EOR Receipt Date: Column H - ESIS paid only a single Med-Legal bill after daisyBill intervention
  • Patient Name: Column S
  • Claim Number: Column T

daisyBill Attempts to Contact ESIS Regarding Missing Payments

daisyBill left dozens of voicemails to ESIS adjusters and supervisors. In all but three instances, ESIS failed to respond.

DOS

Employer

Bill Submit Date

Payment Overdue

Balance Due

Call Notes

4/20/2022

ABM Industries

5/20/2022

83

$2,216.50

Per ESIS Medbill Impact, the bill was received on 5/24/2022 and processed on 6/1/2022. Payment is pending adjustor approval.

Called ESIS claims department for adjustor info and left VM with adjustor. Adjustor called back indicating payment will be issued in full. As of this writing, the provider has not received the payment.

2/15/2022

AAA Northern California, Nevada and Utah

3/2/2022

162

$650.00

Per ESIS Medbill Impact, the bill was received on 3/4/2022 and processed on 4/13/2022. Payment is pending adjustor approval.

Called ESIS claims department for adjustor info and left VM with adjustor. As of this writing, the provider has not received the payment.

3/3/2022

AAA Northern California, Nevada and Utah

4/6/2022

127

$1,316.25

Per ESIS Medbill Impact, the bill was received on 4/8/2022 and processed on 4/14/2022. Payment is pending adjustor approval.

Called ESIS claims department for adjustor info and left VM with adjustor. As of this writing, the provider has not received the payment.

5/9/2022

Constellation Brands, Inc.

5/26/2022

62

$2,921.75

Per ESIS Medbill Impact, the bill was received on 5/31/2022 and processed on 6/3/2022. Payment was approved on 7/27/2022. The provider received payment WITHOUT penalty or interest.

1/18/2022

Staffing Network

3/3/2022

161

$2,015.00

Per ESIS Medbill Impact, the bill was received on 3/4/2022 and processed on 5/3/2022. Payment is pending adjustor approval.

Called ESIS claims department for adjustor info and spoke with adjustor. Per adjustor, payment was withheld due to a missing pay code error. ESIS switched systems last year, which has been causing a lot of bills to be placed in incorrect queues. During the call the Adjustor reported manually changing the pay code to DMX for QME and released payment in full. As of this writing, the provider has not received the payment.

4/7/2022

Staffing Network

4/12/2022

121

$650.00

Per ESIS Medbill Impact, the bill was received on 4/14/2022 and processed on 5/3/2022. Payment is pending adjustor approval.

Called ESIS claims department for adjustor info and spoke with adjustor. Per adjustor, payment was withheld due to a missing pay code error. ESIS switched systems last year, which has been causing a lot of bills to be placed in incorrect queues. During the call the Adjustor reported manually changing the pay code to DMX for QME and released payment in full. As of this writing, the provider has not received the payment.

10/22/2021

Allied Universal

11/42021

280

$503.75

Per ESIS Medbill Impact, bill was received on 11/8/2021 and processed on 11/16/2021. Payment is pending adjustor approval.

Called ESIS claims department for adjustor info and left VM with adjustor. As of this writing, the provider has not received the payment.

1/12/2022

Allied Universal

2/16/2022

176

$2,015.00

Per ESIS Medbill Impact, bill was received on 2/18/2022 and processed on 3/3/2022. Payment is pending adjustor approval.

Called ESIS claims department for adjustor info and left VM with adjustor. As of this writing, the provider has not received the payment.

3/29/2022

Allied Universal

4/4/2022

129

$650.00

Per ESIS Medbill Impact, the bill was received on 4/6/2022 and processed on 4/12/2022. Payment is pending adjustor approval.

Called ESIS claims department for adjustor info and left VM with adjustor. As of this writing, the provider has not received the payment.

8/10/2021

ABM Industries, Inc.

9/8/2021

337

$2,216.50

Per ESIS Medbill Impact, the bill was received on 9/10/2021 and processed on 9/30/2021. Payment is pending adjustor approval.

Called ESIS claims department for adjustor info and left VM with adjustor. As of this writing, the provider has not received the payment.

News Articles published by daisyNews:

Audit Complaint Details

Bill Transmission: Medical-Legal Original Bill - Payment Missing

Non-compliance: Claims administrator failed to remit payment for Medical-Legal expenses within 60 days after receipt of bill and supporting documents as mandated by California Code of Regulations Section 9794(b).

Per Labor Code Section 4622(a)(1), within 60 days after receipt by the employer of each separate, written billing and report, and if payment is not made within this period, that portion of the billed sum then unreasonably unpaid shall be increased by 10 percent, together with interest thereon at the rate of 7 percent per annum retroactive to the date of receipt of the bill and report by the employer.


Protect your practice. Harness the power of daisyBill software, data, and expertise for faster, better workers’ comp billing. Reach out to learn how we can help.

CONTACT US

How did you like the article ?

DaisyBill provides content as an insightful service to its readers and clients. It does not offer legal advice and cannot guarantee the accuracy or suitability of its content for a particular purpose.