WSIA

Original Policy

In November 2016, Group Health - now Kaiser Permanente Washington (KPWA) – announced pharmacy billing process changes for self-insured claims. As a result of an electronic medical record (EMR) upgrade, Group Health is no longer able to bill an employer's insurance carrier directly for workers' compensation claim-related medications. Effective November 6, patients were informed that they would need to pay for medications at the time they were dispensed and then acquire reimbursement from the self-insured insurance carrier. Patients were also provided outside options to receive their medications. This change only applied to medications related to self-insured on-the-job injury claims. The change did not apply to medications covered by an employee’s health plan.

The Group Health|KPWA EMR upgrade no longer supports paper billing and reimbursement, which was how billing for self-insured claims was historically conducted. Since the November announcement, Group Health|KPWA has worked with members of WSIA and learned that most self-insured employers accept electronic pharmacy claim billing through a pharmacy benefit manager (PBM).  

Policy Change

Group Health|KPWA is committed to working with self-insured employers with electronic billing capability to establish accounts so that pharmacy bills can be directly billed to the self-insured employer or their PBM. Initially, Group Health|KPWA will set up accounts with Optum, which has many major self-insured employer accounts. Using a phased-in approach will allow Group Health|KPWA time to identify the level of effort required to develop accounts and test connectivity. 

At this time, if a self-insured employer does not have electronic billing capability for pharmacy claims, Group Health’s|KPWA policy announced in November will remain in effect. Group Health|KPWA is currently analyzing required system changes that would allow paper billing and the volume of claims of self-insured employers that only accept paper.

If you would like to work with Group Health|KPWA to set up electronic pharmacy billing, contact Tom Lehmann at Lehmann.t@ghc.org or (206) 326-3931.