Workers’ compensation claims are complicated, especially when it comes to the issue of resolving bills from medical providers. You may have come across an unfamiliar industry-specific term — EOR. As defined in the state’s Workers’ Compensation Medical Billing and Payment Guide, Explanations of Review (EORs) are the “explanation of payment or the denial of payment” in a workers’ compensation claim.

The payer of workers’ compensation benefits should understand what EORs are and the requirements set forth by California’s law. Here, our Fresno workers’ compensation defense attorneys explain the most important things you should know about workers’ compensation billing and Explanations of Review (EORs).

Workers’ Compensation Covers Medical Treatment—But Health Care Billing is Complicated

Under California law, businesses and organizations are required to provide no-fault workers’ compensation benefits for employees. If a worker is injured in the course and scope of their employment, they can file for benefits. The California Department of Industrial Relations emphasizes that workers’ compensation benefits include “medical care” paid for by an employer.

Of course, disputes can arise of what types of medical treatment are reasonable and necessary given the nature and severity of an employee’s injuries/impairments. Additionally, disputes can also arise between workers’ compensation payers (insurers/claims administrators) and health care providers over the cost of services. This is where Explanations of Review (EORs) can become an issue.

Explanations of Review (EORs) Help to Facilitate Workers’ Compensation Billing 

The EOR process is designed to help ensure clear, reliable communication between workers’ compensation claims administrators and health care providers. Under California law (California Labor Code Section 4603.3), an employer (and its claims administrator) has a legal responsibility to provide certain information regarding the payment, adjustment, or denial of a medical bill for workers’ compensation related services. This must be done through an EOR which should include:

  • The total amount paid;
  • The grounds for adjusting or denying any item on the bill; and/or
  • The additional information needed for payment, if a portion of the payment has been delayed due to incomplete documentation from the provider.

The Bottom Line: Workers’ compensation-related billing disputes can arise between claims administrators and health care providers. California requires parties to use legally compliant Explanations of Review (EORs) to ensure that accurate information is being exchanged between the parties. An insurance company, claims administrator, or employer that fails to follow its obligations under the California Labor Code could run into serious problems. Since there are strict deadlines for submitting and responding to EORs, it is important to be proactive.

Contact Our Fresno, CA Workers’ Compensation Defense Lawyers Today

At Yrulegui & Roberts, our California workers’ compensation defense attorneys possess the legal skills and expertise that you can rely on to protect your best interests. If you have any questions about workers’ compensation EORs, we are more than happy to help. Contact us today for a fully confidential review and assessment of your case. We provide workers’ compensation defense services throughout Fresno County, including in Fresno, Clovis, Reedley, Selma, Sanger, and Coalinga.