A California provider will no longer treat injured workers if ESIS, Inc. is the claims administrator.

The provider apparently concluded that membership in the Third-Party Administrator (TPA)’s Medical Provider Network (MPN) is a net negative for the practice because “they do not pay.”

An injured worker’s attorney shared an email exchange in which the provider’s Office Manager announced their “no ESIS” policy and informed the attorney that the practice would “love for them to remove us from their MPN.”

Based on years of data and reporting (as well as formal complaints to state authorities), many providers should echo this practice’s sentiments. If more practices said “enough,” perhaps ESIS would conclude that abusing providers has consequences.

Practice re: ESIS: “They Do Not Pay”

The injured worker’s attorney contacted the practice for an appointment, but the Office Manager declared that the practice is “not accepting ESIS insurance” and asked the attorney to “redirect” the injured worker to a different provider.

When the attorney pointed out that the doctor is a member of an ESIS MPN, the Office Manager stated (emphases ours):

“We have chosen not to accept ESIS, because we have had several claims with them and they do not pay. I would love for them to remove us from their MPN.”

Apparently, the supposed “benefits” of MPN membership (almost always offered in exchange for deep reimbursement discounts) are meaningless when the claims administrator refuses to reimburse the MPN doctors.

This isn’t the first time providers have complained about ESIS’s payment abuse. The list of complaints includes ESIS:

• Refusing payment, only to abruptly reverse their decision when the provider appealed to the state for Independent Bill Review
• Ignoring a provider’s bills for months, then ignoring multiple phone calls from the provider and daisyCollect
• Denying payment based on demonstrably untrue claims of missing documentation
• Rejecting 171 valid e-bills for random and nonsensical reasons

ESIS has little incentive to pay providers correctly. As daisyNews has documented thoroughly, the California Division of Workers’ Compensation (CA DWC) consistently fails to impose consequences on claims administrators who engage in these payment shenanigans.

Without regulatory consequences, behavior like ESIS’s is the inevitable result.

ESIS EDI Stats: A Bad Look

Whether it’s consistent with ESIS’s penchant for non-payment or simply due to technical ineptitude, ESIS is among the worst claims administrators in our system for Electronic Data Interchange (EDI) performance.

EDI refers to the exchange of digital information in e-billing transactions. We assign each claims administrator in our system an “EDI Grade” based on how well they accept and respond to e-bills.

Using data from over 78,500 ESIS bills sent by our clients in the last 365 days, ESIS is assigned an EDI Grade of F.

ESIS’s low score is almost entirely due to the TPA’s failure to send electronic Explanations of Review (e-EORs) in response to e-bills.

Many ESIS e-EORs are either missing or faulty beyond use. In cases of missing e-EORs, ESIS either forced the provider to post payment details manually with a paper EOR, or they didn’t pay at all.

ESIS has completely lost the trust of at least one California provider. The TPA has inflicted payment abuse on countless others. We applaud this practice for insisting on fair treatment and enforcing what should be a non-negotiable boundary.

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