Third-Party Administrator (TPA) Tristar Risk Management continues to ignore California workers’ comp billing regulations with impunity.

Tristar failed to send electronic Explanations of Review (e-EORs) for almost 94% of e-bills submitted by providers from March 30, 2023, through June 14, 2023.

Critical to e-billing, e-EORs automatically post the payment to the e-bill, saving providers countless hours of manual work — which is the reason California regulations require claims administrators to return an e-EOR within 15 working days of receiving an e-bill.

Today, daisyBill filed 3,678 Audit Complaints with the Division of Workers’ Compensation (DWC), reporting Tristar’s failure to send e-EORs to daisyBill providers during this two-and-a-half-month period.

Additionally, daisyBill requested the DWC provide instructions on filing a request for a targeted profile audit review of Tristar.

California regulations mandate a $100 penalty for each instance of failure to comply with DWC regulations. Given Tristar’s blatant violations, at $100 a pop, the DWC could quickly motivate Tristar with $367,800 in reasons to get its act together. The question is: will the DWC impose monetary penalties? As we know, there is no law unless enforced (although historical precedent suggests that no thinking person should hold their breath for the announcement of penalties by the DWC).

Tristar’s employer and insurer clients should take notice of the verifiable data below, which demonstrates the TPA’s blatant lack of compliance with California law.

To: XXXXXXXX@dir.ca.gov

Subject: Tristar EDI Non-compliance: X12 835 Missing - Count 3,678

Below is an Audit Complaint reporting credible data that Tristar Risk Management failed to send 3,678 electronic EORs (X12 835) to daisyBill providers as mandated by California law.

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.

This Audit Complaint data represents California workers’ comp e-bills submitted to Tristar Risk Management by daisyBill providers from March 30, 2023 through June 14, 2023.

Attached is a CSV list containing 3,678 e-bills providers submitted where Tristar failed to return a mandated electronic EOR to the provider. The attached CSV list includes the following columns:

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

Audit Complaint Details

This Audit Complaint Data submitted to the DWC represents a credible complaint and credible information of claims handling violations. Per Title 8, California Code of Regulations section 10111.2(b)(10),(11), Tristar should be subject to audit penalties.

EDI Non-compliance: Claims administrator failed to send an electronic Explanation of Review (EOR) in the mandated ASC X12N/005010X221A1 (835) format, despite the claims administrator sending a 277 Acknowledgement accepting the Original Bill / Second Review Appeal.

DWC Rule 7.1 requires the claims administrator to electronically send an EOR to the provider using the X12 835 EDI standard within 15 working days of receipt of an e-bill.

Per California DWC Medical Billing and Payment Guide 7.2, any electronically submitted bill determined to be completed, not paid, or objected to within the 15 working day period shall be subject to audit penalties per Title 8, California Code of Regulations section 10111.2(b)(10),(11).

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