Across the nation, many doctors avoid taking on workers’ comp patients for one simple reason: obtaining payment can be a nightmare.

Electronic billing (e-billing) has solved or mitigated many of comp’s major billing issues, like document management and long wait times for reimbursement. But those benefits only materialize when payers hold up their end of the bargain by complying with state e-billing laws and regulations.

Third-Party Administrators (TPAs) play a key role in the workers’ comp billing ecosystem, managing claims for countless self-insured employers and often for insurers. For that reason, we looked at our daisyData to see which TPAs are helping or hurting the system overall.

Today, we share the five top-performing TPAs in our system, as measured by our Electronic Data Interchange (EDI) grading system.

A TPA that properly processes and responds to providers’ e-bills makes it easier for those providers to accept and treat injured workers. Providers can submit e-bills and know that the TPA will respond compliantly and electronically close the loop in the payment cycle, eliminating the need for excessive administrative efforts to manage payments.

That's why the TPAs below stand out: each has a data-backed track record of consistent, compliant e-billing performance, making it easier for providers to say “yes” to treating injured workers.

Top 5 TPAs by EDI Compliance Grade

Over the last 365 days, the five TPAs below maintained the highest EDI Grades among our largest TPAs by bill volume.

A few achievements worth noting:

• CorVel not only functions as a TPA, it’s also its own clearinghouse. That makes its ‘A-’ compliance even more impressive. All other TPAs outsource e-bill acceptance and responses, including the issuance of electronic Explanations of Review/Benefits (e-EORs/EOBs), to outside clearinghouse vendors.
• Gallagher Bassett has room for improvement with its ‘B’ Grade, specifically in the crucial area of e-EOR/EOB remittance. However, its otherwise excellent performance is laudable given the sheer volume of bills; Gallagher Bassett is the second-largest payer in our entire system.
• Helmsman has the highest Grade among our higher-volume TPAs, with an ‘A.’ Keep it up!

How We “Grade” TPAs

Our Claims Administrator and Network Directory assigns every payer an EDI “Grade” based on four factors, drawing data from the millions of e-bills our clients submit annually.

Each factor refers to a standard electronic file type used in e-billing (e.g., ‘837’ is the compliant format for an electronic CMS-1500 billing form). Each factor is weighted to reflect its impact on providers’ revenue management:

• 837 Sent (e-Bill): How often the payer accepts compliant e-bills (Grade Weight: 15%)
• 277 Timely Receipt: How often the payer issues a timely electronic “receipt” indicating acceptance or rejection of the e-bill (Grade Weight: 5%)
• 277 Accept/Reject: How often the payer accepts compliant e-bills for processing, as opposed to improperly rejecting them (Grade Weight: 5%)
• 835 Posted (EOR/EOB): How often the payer sends compliant e-EOR/EOBs in response to e-bills (Grade Weight: 75%)

As the Grade Weights indicate, the basic duty to accept an e-bill and confirm receipt is the bare minimum of EDI compliance. The factor that really tends to differentiate payers is sending compliant e-EORs/EOBs, which arguably has the biggest impact on providers.

e-EORs automatically post payment details to the provider’s e-billing system, saving innumerable hours of manual work and allowing for hyper-efficient revenue management, hence the 75% weighting and its impact on each TPA’s overall performance Grade.

In our next article, we’ll share the Grades of our poorest-performing major TPAs (including Sedgwick).

When an employer chooses a TPA, they are putting critical aspects of their injured employees’ healthcare in that TPA’s hands. Beyond a simple matter of compliance or cost control, an employer’s choice of TPA can impact health outcomes, claim durations, and disability claims.

Choose wisely.

daisyBill gets providers paid faster and more accurately for injured workers’ treatment. Click below to see how:  

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