ESIS, a third-party administrator (TPA) for Ace American Insurance, is failing miserably in its legal duty to timely reimburse a California physician evaluator for Medical-Legal services.

Even after ten attempts to speak to ESIS, and being placed on hold for almost 3 hours, the doctor failed to receive payment from ESIS for the supplemental Medical-Legal evaluation requested by ESIS.

As we’ve pointed out many, many times, ESIS’s lack of payment is completely logical, as there are no consequences for inflicting either payment or phone abuse on this Medical-Legal evaluator. As we have also pointed out many, many times, neither California legislators nor California regulators appear to care whether ESIS adheres to workers’ comp payment laws and regulations.

Until this physician hires an attorney to appear before the WCAB, there are zero reasons for ESIS to bother paying this doctor, or answering its phone when the doctor calls to find out why ESIS isn’t paying.

We regularly hear complaints from client and non-client physician evaluators about improper denials and adjustments of Medical-Legal bills for wildly inapplicable reasons — like the physician not being in the payer’s Medical Provider Network (MPN), Preferred Provider Organization (PPO) discounts, and other baseless (read: false) rationales.

But ESIS’s recent failure to remit the Explanation of Review (EOR) or payment (and its flat-out refusal to answer its phone) is a new level of hyper-noncompliance.

This ESIS provider payment abuse is the precise reason physicians refuse to participate in California workers’ compensation. All California employers should be enraged.

ESIS: Med-Legal Payment Waaaaay Overdue

On behalf of our physician client, daisyCollect submitted an original bill to ESIS for Medical-Legal services on October 18, 2021. Per California Labor Code Section 4622, ESIS has 60 days to remit payment and the EOR to the physician:

“All medical-legal expenses for which the employer is liable shall, upon receipt by the employer of all reports and documents required by the administrative director incident to the services, be paid to whom the funds and expenses are due, as follows:

(a) (1) Except as provided in subdivision (b) [which outlines the provider’s appeal process to dispute incorrect reimbursements], within 60 days after receipt by the employer of each separate, written billing and report…” [emphasis added]

As the daisyBill screenshot below shows, ESIS acknowledged receiving the complete bill on October 21, 2021 — making the deadline for the EOR and payment December 20, 2021.

As of this writing (in February of 2022), ESIS has refused to pay the evaluator for the Medical-Legal evaluation report.

ESIS Soils California Workers’ Comp With Impunity

When the physician heard nothing but crickets back from ESIS, our daisyCollect team reached out to the TPA. And the ESIS torture commenced.

Call #1 - ESIS Bill Review Refused to Disclose Payment information. An ESIS representative told daisyCollect that ESIS processed the Medical-Legal bill, but that payment was waiting on “adjustor approval.” The ESIS representative refused to share any further details (including the reimbursement amount) and refused to provide the adjustor’s name or contact information.

Call #2 - daisyCollect called the main ESIS number; we were transferred to an ESIS representative who provided the adjuster's name and telephone number.

Call #3 - daisyCollect called the ESIS adjuster. The adjuster did not answer the phone, and the adjuster’s voice mailbox was full. No message left.

Calls #4, #5, #6 - daisyCollect left three separate voice messages for the adjuster's supervisor. Shockingly (not), the supervisor ignored the messages (again, again, and again).

Call #7 - daisyCollect called the ESIS adjuster (again) who did not answer the phone (again) and the adjuster’s voice mailbox was full (again). No message left.

Call #8 - daisyCollect called ESIS Bill Review (again), and the ESIS Bill Review representative provided a new telephone extension for daisyCollect to try.

Call #9 - daisyCollect called the new telephone extension provided by ESIS, which routed our call back to…ESIS Bill Review (sigh).

This time, ESIS Bill Review confirmed recommending that ESIS pay the Medical-Legal bill in full. This time, ESIS Bill Review instructed us to call the ESIS main number and to remain on hold to speak to a live ESIS representative.

Call #10 - As advised by ESIS Bill Review, daisyCollect called the ESIS main line. daisyCollect was on hold for a full 2 hours and 52 minutes. daisyCollect finally hung up without speaking to anyone (yes, we have the phone record to prove this absurd ESIS physician abuse).

Three Critical Facts

As a TPA with years of experience handling California workers’ comp claims, ESIS has no excuse for failing to comply with the most basic requirements of Medical-Legal reimbursement.  

Here are the three most critical facts readers MUST remember:

1. With its contorted (and abusive) workers’ comp payment laws and regulations, California encourages claims administrators to refuse payment for Medical-Legal services and medical treatment.  
2. This physician’s only recourse is to expend enormous administrative resources to hire an attorney to appear before the Workers Compensation Appeal Board (WCAB) to ask a judge to demand that ESIS pay the doctor.
3. This payment abuse by claims administrators, endorsed by legislators and regulators, is forcing doctors to refuse to treat California’s injured workers.

This tale clearly demonstrates that California workers’ comp is nothing short of a torture chamber that allows claims administrators like ESIS to inflict provider payment abuse with impunity.

daisyBill knows the rules — even though claims administrators don’t always follow them. Reach out to learn how our technology and expertise can protect your revenue from payer noncompliance.

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