ExamWorks Compliance Solutions

What ExamWorks Compliance Solutions does

ExamWorks Compliance Solutions, LLC is a privately held compliance services firm headquartered in Lawrenceville, Georgia, specializing in Medicare Secondary Payer compliance, Medicare Set-Aside (MSA) allocations, and mandatory insurer reporting under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA). The firm serves Responsible Reporting Entities (RREs), insurers, self-insured entities, and plan administrators across workers' compensation, liability, and no-fault claims. Its core offerings span four solution areas: Claims Resolution (Pre-Medicare Set-Aside, Claims Settlement Allocation, Life Care Plan, Legal Nurse Review, Medical Cost Projections); Medicare Compliance (Medicare Set-Aside, Evidence Based MSA, Liability MSA, Conditional Payments); Outcome Management (RxD, RxAnalysis, Physician Outreach); and Mandatory Insurer Reporting (Section 111 Reporting, Civil Money Penalty Compliance). Underlying delivery relies on a proprietary compliance and reporting platform with CMS integrations and HIPAA-aligned data infrastructure, plus two MFA-secured web portals — the MSP Referrals Portal and iService — that together ingest data from over 700 sources and serve over 3,000 RREs, making ECS the largest reporting vendor in the Section 111 space by its own account.

The firm's clinical backbone is provided by in-house Certified Life Care Planners and on-staff Doctors of Pharmacy, who have collectively completed over 300,000 MSAs. Reported customer outcomes include $335MM+ saved through Conditional Payment Services, $45MM saved through Agreed Pharmacy Reductions, and a 99% CMS acceptance rate. The firm holds SOC 2 certification via the AICPA and maintains HIPAA-aligned controls for Protected Health Information handling.

Revenue is generated through professional services and per-transaction fees for compliance and reporting engagements, with pricing determined on a quote basis per engagement rather than published tiers. Distribution combines enterprise field sales (National Account Managers, Regional Compliance Consultants) with self-serve portals, a 866-MSA-FILE referral intake line, content marketing, and a referral program. The firm operates solely in the United States and is independently owned, with no parent company, venture capital backing, or institutional investor involvement disclosed in the source material.

Name

ExamWorks Compliance Solutions

Legal name

ExamWorks Compliance Solutions, LLC

Website

https://examworks-cs.com

Company type

Private

Founded year

2009

Operating status

Operating

Headcount range

101–250 employees

Short description

ExamWorks Compliance Solutions provides Medicare Set-Aside, Section 111 mandatory insurer reporting, and claims resolution services to insurers, self-insured entities, and over 3,000 Responsible Reporting Entities, leveraging proprietary portals and in-house clinical staff.

Ownership category

akta.pro rank

Product category

Medicare Compliance and Mandatory Insurer Reporting Services

NAICS

Offices of Physicians (6211)

SIC

Services-Health Services (8000), Hospital & Medical Service Plans (6324)

akta.pro primary industry

Payer-Provider Data Exchange (X12, prior auth, claims/clinical attachment) (HLACABAK)

akta.pro secondary industry

Claims Administration & Payment Integrity (Medical/Dental/Vision) (HLAEALAD)

Keywords

• Medicare compliance services
• Medicare Set-Aside arrangements
• Section 111 reporting
• Claims resolution services
• Mandatory insurer reporting

Headquarters

HQ city

Lawrenceville

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Technology or R&D, Operations, Marketing or Sales, Infrastructure

Revenue model

1. Compliance and Reporting Services: ECS generates revenue through professional services for Medicare compliance, mandatory insurer reporting, and claims resolution. Services include Medicare Set-Aside calculations, Conditional Payment Services, Section 111 Reporting, and Outcome Management solutions. Revenue is derived from per-transaction fees for reporting and compliance services as well as service fees for claims resolution engagements.

Go-to-market motion1 record

Distribution channels4 records

Marketing channels5 records

Core offering

ExamWorks Compliance Solutions delivers professional Medicare compliance and mandatory insurer reporting services for insurers, self-insured entities, and other Responsible Reporting Entities (RREs). The offering spans Medicare Set-Aside (MSA) calculations, conditional payment identification and resolution, Section 111 Mandatory Insurer Reporting under MMSEA, claims resolution services (pre-Medicare set-aside, life care planning, legal nurse review, medical cost projections), and outcome management (RxD, RxAnalysis, physician outreach). Service delivery is supported by two proprietary client-facing portals — iService for Section 111 reporting and the MSP Referrals Portal — that ingest data from over 700 sources for reporting on behalf of over 3,000 RREs, with 300,000+ MSAs completed by in-house Certified Life Care Planners and on-staff Doctors of Pharmacy.

Product overview

ExamWorks Compliance Solutions is a compliance technology platform offering a unified suite of four core service areas: Claims Resolution, Medicare Compliance, Outcome Management, and Mandatory Insurer Reporting. The platform operates through web-based portals including the MSP Referrals Portal and iService for Section 111 Reporting. Under Claims Resolution, the company offers Pre-Medicare Set-Aside, Claims Settlement Allocation, Life Care Plan, Legal Nurse Review, and Medical Cost Projections. Medicare Compliance includes Medicare Set-Aside, Evidence Based Medicare Set-Aside, Liability Medicare Set-Aside, and Conditional Payments. Outcome Management encompasses RxD, RxAnalysis, Physician Outreach, and Outcome Management services. Mandatory Insurer Reporting covers Section 111 Reporting and Civil Money Penalty Compliance. The company leverages over 300,000 MSAs completed by in-house Certified Life Care Planners and Doctors of Pharmacy, and serves as the largest Section 111 reporting vendor receiving data from over 700 sources for over 3,000 RREs.

Differentiator

Problem solved

Functional benefit

Brands

• iService: Online platform for Section 111 Mandatory Insurer Reporting services
• ECS Customer Portal
• RxD
• RxAnalysis

Products and services

• Claims Resolution Comprehensive claims resolution services for entities seeking resolution of claims involving Medicare interests, including Pre-Medicare Set-Aside, Claims Settlement Allocation, Life Care Plan, Legal Nurse Review, and Medical Cost Projections. Designed for workers' compensation, liability, and no-fault claims.
• Medicare Compliance Medicare compliance solutions for Responsible Reporting Entities (RREs), insurers, and self-insured entities, including Medicare Set-Aside, Evidence Based Medicare Set-Aside, Liability Medicare Set-Aside, and Conditional Payments services for claims settlement involving Medicare beneficiaries.
• Outcome Management Outcome management services including RxD, RxAnalysis, Physician Outreach, and Outcome Management solutions that manage pharmacy costs and coordinate physician care in post-settlement workers' compensation and liability claims.
• Mandatory Insurer Reporting Mandatory insurer reporting solutions including Section 111 Reporting and Civil Money Penalty Compliance for insurers, self-insurers, and plan administrators required to report under Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA), covering both NGHP and GHP reporting.
• iService Platform Web-based platform for Section 111 Mandatory Insurer Reporting with Multi-Factor Authentication, providing secure access for MMSEA Section 111 compliance reporting for insurers, self-insurers, and plan administrators.
• MSP Referrals Portal Customer portal for Medicare Secondary Payer (MSP) referrals, MSP compliance services, and claims management with secure login access, enabling customers to submit Medicare Set-Aside referrals and claims resolution requests.

Quantifiable outcome

• 99% CMS Acceptance rate
• +3 more outcomes

Segments4 records

Ideal customer profiles1 record

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Feature3 records

Scale indicators6 records

Recent moves5 records

Expansion highlights4 records

Broad incumbents

• Change Healthcare (Optum): Change Healthcare, now part of Optum, operates a large healthcare data exchange and claims processing network. Highly relevant as a payer-provider data exchange peer to ECS's Section 111 reporting infrastructure.
• Sedgwick (MSPC): Sedgwick is a large global claims and managed care services provider that acquired MSPC, a Medicare compliance vendor. It overlaps with ECS on Section 111 reporting and MSA services, but operates across a much broader claims management portfolio.
• Verisk (Claims Solutions / ISO): Verisk provides analytics, claims data, and compliance software across the property & casualty and workers' comp industry. Overlaps with ECS through payer-provider data exchange and claims analytics, but as part of a much broader data and analytics portfolio.

Direct peers

• Tower MSA Partners: Tower MSA Partners specializes in Medicare Set-Aside allocation and administration for workers' comp and liability claims. A focused direct competitor to ECS's core MSA service line.
• Helios (formerly ScripNet / JS Held): Helios provides pharmacy benefit and cost containment services in workers' comp and liability claims. Directly comparable to ECS's RxD, RxAnalysis, and Outcome Management pharmacy services.
• Genex Services: Genex delivers MSA allocation, case management, and disability management services to insurers and employers. Directly comparable to ECS's Medicare Set-Aside and claims resolution offerings for the same workers' comp customer base.
• Mitchell International: Mitchell provides workers' compensation claims management, medical bill review, and pharmacy analytics software used by insurers and self-insureds. Highly comparable to ECS on the technology-enabled claims/Medicare compliance side of the workers' comp value chain.
• MEDVAL: MEDVAL provides MSA preparation, conditional payment resolution, and Section 111 reporting services. A specialized direct peer competing for the same Responsible Reporting Entity customers.
• Apricity Services: Apricity offers MSA, conditional payment, and Section 111 compliance services to insurers, self-insureds, and TPAs. Directly comparable niche competitor with overlapping product set and customer base.

Others

• LexisNexis Risk Solutions: LexisNexis Risk Solutions supplies data and analytics used by insurers for claims, fraud, and compliance workflows. Adjacent peer enabling similar payer-provider data exchange and risk decisioning for the same insurance customers.

Market position

Strengths5 records

Weaknesses4 records

Competitive moat5 records

Key risks5 records

Key highlights6 records

Customer concentration

Compliance2 records

Revenue estimate

Valuation estimate

Number of profiles

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about ExamWorks Compliance Solutions