The Los Angeles County Metropolitan Transit Authority (LA Metro) is making it harder for California doctors to treat its injured employees—and has given no indication of taking responsibility for its failures, instead relying on vendors to address complaints of increasing non-compliance.

Despite daisyBill’s persistent outreach and previous Audit Complaints to the California Division of Workers’ Compensation (DWC), LA Metro continues to ignore a fundamental e-billing obligation: timely sending providers electronic Explanations of Review (e-EORs).

Accordingly, this week daisyBill submitted Audit Complaints to the DWC reporting 4,955 new violations by LA Metro. Previously on July 17, 2024, daisyBill submitted Audit Complaints reporting 12,879 e-EOR violations, bringing the grand total to 17,834.

It’s beyond argument that e-billing makes workers’ comp more efficient and effective for both payers and providers. However, for e-billing to work correctly, claims administrators (including public self-insured employers like LA Metro) must hold up their end of electronic transactions.

e-EORs improve workers’ comp by automatically posting payment details to providers’ e-billing systems, enabling faster, better, more efficient revenue management. In other words, e-EORs allow doctors to focus time and administrative resources on injured workers rather than (literal) paperwork.

This seems to be lost on LA Metro, as is the basic principle that claims administrators—not vendors—are ultimately responsible for compliance with workers’ comp requirements.

While we have little faith that the DWC will take substantive action, daisyBill cannot (and should not) assume the role of “compliance police,” endlessly hounding recalcitrant claims administrators on behalf of California providers.

LA Metro e-EOR: 29% Compliant

When a provider electronically sends a bill to a claims administrator, California e-billing regulations require that claims administrator to respond by sending an e-EOR within 15 working days after receipt of the e-bill.

In e-billing lingo, the electronic EOR is known as an X12 835 transmission. Below, our Claims Administrator Directory demonstrates that LA Metro complied with California e-billing regulations for only 29% of e-bills daisyBill transmitted to LA Metro between 9/1/2023 and 8//31/2024.

This X12 835 data shows that LA Metro failed to send e-EORs for 16% of providers’ e-bills, and sent an untimely e-EOR for 54% of providers’ e-bills.

LA Metro: Passing the Buck to Vendors

Since July of this year, daisyBill has been in contact with LA Metro and two of its vendors, Lien On Me and CompIQ, about consistent e-EOR non-compliance.

Note that in California, LA Metro is legally responsible for compliance with workers’ comp payment requirements, regardless of any vendors involved. As the DWC Electronic Medical Billing and Payment Companion Guide states (emphasis ours):

“Billing agents, electronic billing agents, third party administrators, bill review companies, software vendors, data collection agents, and clearinghouses are examples of companies that may have a role in electronic billing. Entities or persons using agents are responsible for the acts or omissions of those agents executed in the performance of services for the entity or person.”

daisyBill first alerted LA Metro of the non-compliance on July 1, by emailing LA Metro’s Workers’ Compensation Director with the details of missing and untimely e-EORs. The Director forwarded the email to Lien On Me but took no further action that we know of.

On July 17, 2024, with no apparent resolution in sight, daisyBill submitted 12,879 Audit Complaints to the DWC top report LA Metro’s e-EOR non-compliance

Following the first batch of audit complaints, Lien On Me’s vice president assured daisyBill they were working with CompIQ to send providers e-EORs compliantly. Further, the Vice President requested that daisyBill contact Lien On Me directly to report any future problems with LA Metro.

But by late August, LA Metro’s e-EOR non-compliance had increased.

LA Metro Non-Compliance (and Buck-Passing) Persist

On August 21, daisyBill emailed executives at all three entities involved (LA Metro, Lien On Me, and CompIQ) with the details of the continued and increasing non-compliance.

In response, LA Metro’s Workers’ Compensation Director emailed Lien On Me, asking the vendor to address daisyBill’s “very broad claim” of non-compliance. Lien On Me subsequently arranged a conference call with CompIQ and daisyBill. During the call, the two LA Metro vendors acknowledged the non-compliance and pledged to find a solution.

CompIQ remained in contact with daisyBill and provided updates. But for all CompIQ’s assurances, LA Metro’s non-compliance continued. In late October, daisyBill emailed CompIQ to report worsening non-compliance, including the following statistics:

• For August e-bills, LA Metro failed to send e-EORs for 22% of e-bills; 30% of e-EORs received for August e-bills were untimely
  
• For September e-bills, LA Metro failed to send e-EORs for 42% of e-bills; 32% of e-EORs received were untimely

Again, CompIQ offered apologies and reassurances, but the problem remained unresolved. With no other recourse, daisyBill emailed LA Metro announcing our intention to file additional Audit Complaints. We have received no response from LA Metro.

Throughout this ordeal, daisyBill providers were forced to waste time and resources manually entering payment information from paper EORs (assuming they were paid at all). Meanwhile, LA Metro delegated all communication (and, apparently, all responsibility) to its vendors.

We do not doubt Lien On Me or CompIQ’s honest efforts to resolve the problem. However, LA Metro's effective absence from this process and continued failure to meet its legal obligations (which cannot be foisted onto vendors) leave us no option but to report these continued violations to the state.

Audit Complaint Filed: 4,955 Violations Reported

Yesterday, daisyBill submitted Audit Complaints reflecting 4,955 violations of the e-EOR mandate by LA Metro. The Audit Complaint is reproduced below in its entirety.

To: [redacted]@dir.ca.gov

Subject: Los Angeles County Metropolitan Transit Authority EDI Non-compliance: X12 835 Missing Count 1,644 & X12 835 Late Count 3,311

Hello [Redacted],

Per correspondence with [redacted] exchanged on January 23, 2024, the Audit Unit has no authority over X12 835 EDI non-compliance. [Redacted] advised that the DWC Legal Unit handles these matters.

Below is an Audit Complaint reporting credible data that the Los Angeles Metropolitan Transit Authority (LA Metro) failed to adhere to California EDI regulations, as follows:

1. LA Metro failed to send 1,644 electronic EORs (X12 835) as mandated by California EDI regulations.
2. LA Metro failed to timely send 3,311 electronic EORs (X12 835) as mandated by California EDI regulations.

This Audit Complaint data is aggregated from 4,955 workers’ comp e-bills submitted to LA Metro by daisyBill providers from June 1, 2024 through September 30, 2024.

A provider's receipt of an electronic EOR (X12 835) is a critical component of electronic billing for the following three reasons:

1. The electronic EOR closes the payment loop for a workers’ comp e-bill and
2. Automatically posts to the respective e-bill, thereby significantly reducing a provider's administrative burden of manually recording payment information to the respective e-bill and
3. Allows the gathering of essential payment data about the claims administrator hidden in the paper EORs mailed to individual providers.

On 7/1/2024, I emailed LA Metro Director of Workers’ Compensation Cathy Yates about this EDI non-compliance. More than one month later, the non-compliance persisted.

On 8/21/2024, I emailed LA Metro Director of Workers’ Compensation Cathy Yates again, requesting compliance with California EDI regulations.

On 10/25/2024, I emailed LA Metro Director of Workers’ Compensation Admin Cathy Yates and included data demonstrating that LA Metro non-compliance increased in August and September.

The table below lists the e-Bill and electronic EORs (X12 835) data gathered for LA Metro, showing that LA Metro electronic EOR non-compliance increased in August and September 2024 compared to July 2024, when daisyBill first reported this problem to LA Metro.

I’ve attached two separate CSV lists containing a total of 4,955 e-bills providers submitted to LA Metro demonstrating the following:

#1 LA Metro Electronic EOR (X12 835) Missing - 1,644

For June 1, 2024 through September 30, 2024, this CSV lists 1,644 e-bills daisyBill providers submitted where LA Metro failed to return a mandated electronic EOR to the provider in response to the e-bill. The attached CSV list includes the following columns:

• Column L: [Bill] Transmission Date
• Column W: EOR (835) Compliance Due Date
• Column X: EOR (835) Receipt Date - This column is BLANK because LA Metro failed to send the provider an electronic EOR (835).
• Column AO: Patient Name
• Column AP: Claim Number

#2 LA Metro Electronic EOR (X12 835) Late - 3,311

For June 1, 2024 through September 30, 2024, this CSV lists 3,311 e-bills daisyBill providers submitted where LA Metro failed to timely return a mandated electronic EOR to the provider in response to the e-bill. The attached CSV list includes the following columns:

• Column L: [Bill] Transmission Date
• Column W: EOR (835) Compliance Due Date
• Column X: EOR (835)  - The dates in this column are AFTER the EOR (835) Compliance Due Date
• Column AO: Patient Name
• Column AP: Claim Number

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