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Top 40 Work Comp Claims Administrators and How They Rank in Electronic EOR Compliance

January 20, 2016 by Catherine Montgomery

This article is the second in a series that examines data collected from the 700,000 bills that DaisyBill submitted last year on behalf of our provider clients.

Background: Electronic Billing for Workers’ Compensation in California

Effective October 18, 2012, the state of California mandated that claims administrators must accept and process electronic billing for providers who submit their medical treatment bills electronically. (CA Labor Code § 4603.4)

California Workers’ Comp Electronic Billing Requirements

California’s Division of Workers’ Compensation (DWC) requires that both providers and claims administrators follow the electronic billing rules in the Electronic Billing and Payment Companion Guide.

Three Required Electronic Billing Steps

  1. Providers - Compliantly submit an electronic bill (837) directly to the claims administrator or the claims administrator’s designated clearinghouse.
  2. Claims administrators - Within two days, return an acknowledgment (277) to the provider evidencing receipt of the electronic bill.
  3. Claims administrators - WIthin fifteen working days, for accepted bills, return an electronic explanation of review (835) to the provider.

Problem: Electronic Billing Non-Compliance

Looking at data drawn from over 700,000 bills, in 2015 claims administrators consistently failed to comply with legal requirements when processing providers’ electronic submissions. The most egregious category of non-compliance was failure to return the electronic explanation of review (835) to the provider as required by step 3 of the DWC electronic billing rules.

Three reasons failure to return an electronic EOR is a problem:

  1. Increased billing expenses. Electronic EORs save providers the significant processing costs associated with manually posting paper EORs.
  2. Transparency. Electronic EORs make it possible for providers, claims administrators, and regulators to easily track exactly if, when, and how much bills were paid. No more digging through piles and reams of paper to figure this out.
  3. DWC rules are not optional. Both providers and claims administrators need to follow the rules in order for the workers’ comp system to fully realize the benefits of electronic billing.

Electronic bill submissions also save claims administrators the processing costs associated with paper bills. Providers who take the step--and make investments in technology and staff training to compliantly submit their bills electronically--expect and deserve to receive EORs electronically.

Statistics: 2015 Electronic Explanation of Review

The table below shows statistics for electronic EORs for 2015. Our data reveals that out of the top 40 claims administrators:

  • 14 claims administrators returned no electronic EORs at all.
  • 25 claims administrators returned electronic EORs less than 50% of the time,
  • Only one claims administrator achieved a 100% electronic EOR rate (Hurray Liberty Mutual - I’d nominate them claims administrator of the year if I could!)

Electronic Submission (837) Count of Original Medical Treatment bills submitted between 1/1/2015-12/15/2015 and the returned Electronic EOR (835) Count as of 1/17/2015. The table represents DaisyBill’s top 40 claims administrators sorted by volume.

Claims Administrative Name

Electronic Submission (837) Count

Electronic EOR (835) Count

Electronic EORs Percentage

Sedgwick Claims Management Services (TPA)

46,868

25,597

55%

SCIF - State Compensation Insurance Fund

44,101

13,202

30%

Gallagher Bassett

31,333

20,909

67%

Travelers

18,465

5,331

29%

Liberty Mutual Insurance

17,186

17,186

100%

Zurich Insurance North America

16,711

12,615

75%

York Risk Services Group (TPA)

12,995

0

0%

ESIS

12,272

127

1%

The Hartford

11,027

2,609

24%

AIG / Chartis

10,910

6

0%

Broadspire

10,092

7,845

78%

AmTrust North America

8,615

0

0%

ICW - Insurance Company of the West

7,116

6,260

88%

Employers Compensation Insurance Company

6,929

0

0%

Farmers Insurance Exchange (CorVel)

5,727

2,547

44%

Berkshire Hathaway Homestate Companies

5,550

3,850

69%

Sedgwick (County of Los Angeles 5000 Claims ONLY)

5,004

2,342

47%

York Risk (County of Los Angeles 1000 Claims ONLY)

4,700

2,489

53%

The Zenith

4,609

4,220

92%

Intercare Insurance Services (TPA)

4,084

0

0%

Keenan & Associates

3,686

2,604

71%

CIGA - California Insurance Guarantee Association

3,563

0

0%

American Claims Management

3,512

0

0%

Tristar Risk Mgmt (City of Los Angeles Police Only)

3,143

0

0%

Republic Indemnity

3,139

0

0%

Tristar Risk Mgmt (County of Los Angeles 3000 Claims ONLY)

3,029

1,511

50%

CNA Insurance

2,925

888

30%

Tristar Risk Mgmt (County of Los Angeles 2000 Claims ONLY)

2,763

1,562

57%

CCMSI

2,631

0

0%

Crum & Forster Indemnity Company (CorVel)

2,553

896

35%

York Risk (Walmart / Sam's Club Claims Only)

2,475

0

0%

Chubb Group (CorVel)

2,415

1,161

48%

Applied Risk Services

2,405

0

0%

BBSI - Barrett Business Services Inc. (CorVel)

2,151

655

30%

Intercare (City & County of San Francisco ONLY)

2,092

1,804

86%

Sentry Insurance

2,083

474

23%

Lumbermen's Underwriting Alliance

2,049

1,725

84%

Guard Insurance Group

2,040

1,158

57%

City of Los Angeles

2,037

0

0%

State Farm

1,716

0

0%

What Can I Do?

Providers

If you do not receive electronic EORs for your electronic bill submissions, you can file an Audit Complaint for each non-compliant claims administrator. These articles from our Work Comp FAQ show you how:

  • Original Bill for Medical Treatment and Services

Claims administrators

Contact us.  DaisyBill is happy to share our in-depth knowledge and our data with you.


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About Us

DaisyBill is a trusted authority on workers’ comp billing. Thousands of work comp professionals attend our webinars and state agencies and professional organizations turn to us for our expertise. We created this blog to help everyone involved in workers’ compensation; sharing news, tips, and data of interest to the community.

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