Challenges abound for patients and clinicians alike when it comes to managing gastrointestinal diseases, making it imperative that all stakeholders on the care team—including the patient—continue to hone their knowledge, confidence, and best practice strategies to improve outcomes. But direct patient care is just one piece of the inflammatory bowel disease (IBD) puzzle. The burden of prior authorization related to biologic medicines can significantly impact clinical workflows. Yet, according to a recent survey from the AMA, only 30% of surveyed practices reported that their office lacks a formal process for handling the PA workload.
If this sounds familiar, you’ve come to the right place. CME Outfitters’ Gastroenterology Education Hub provides clinicians with the education and resources necessary to optimize their approach clinical care, as well as prior authorization activities and resources that will help the entire care team—nurses, nurse practitioners, physician assistants, and medical assistants – immediately improve their PA process to ensure consistent approvals that minimize administrative time and streamlines communications with payers.
We’ve added videos and checklists to share with your patients to help them better understand the process and how they can contribute as advocates for their care. Participants who complete the entire prior authorization series will receive not only CME/CE credit but will also be awarded a Certificate of Excellence in Prior Authorization.
Participate in the free CME activities, ask our faculty your tough questions, and download the resources below to improve care and process in the management of patients with IBD.
Uncovering the Secret Sauce: Strategies for Increasing Prior Authorization Success Rates for Patients with IBD
The first module of this CME Outfitters 3-part series is designed to provide you with best practice strategies that you can use to improve your success rates for PA and to minimize the impact of prior authorization on staff administrative time, clinical workflow, and patient care. You’ll have the opportunity to ask our faculty your questions during the activity and get answers to your toughest PA concerns.
Best Practices for EHR Documentation to Overcome Barriers to Prior Authorization for Patients with IBD
In the second module of this CME Outfitters 3-part series, expert faculty will share best practices for creating processes that ensure important clinical information needed for PA is routinely gathered and documented in the patient’s EHR to minimize barriers to biologic approval. You’ll have the opportunity to ask our faculty your questions during the activity and get answers to your toughest PA concerns.
No Doesn’t Necessarily Mean No: Strategies for Successful Prior Authorization Appeals for Patients with IBD
In the third module of this CME Outfitters 3-part series on prior authorization strategies, expert faculty will focus on creating a structured appeals process for when their prior authorization request is declined. You’ll have the opportunity to ask our faculty your questions during the activity and get answers to your toughest PA concerns.
Best Practice Approaches to Prior Authorization for Your Patients with IBD: A 3-Part Series for Improving Processes and Success Rates
Interested in a one-stop webcast that includes all 3 modules? In this 3-part series, faculty will share their best practice approaches for improving PA success rates, including important clinical information that should be routinely gathered and documented in the patient’s EHR to minimize barriers to biologic approval. And when denials happen, they will provide strategies for creating a structured appeal that advocates for the best treatment choice for the patient. Following the successful completion of the series, in addition to credit, CME Outfitters will award a Certificate of Excellence in Prior Authorization. You’ll have the opportunity to ask our faculty your questions during the activity and get answers to your toughest PA concerns.
Putting Processes in Place to Minimize Disruption
I am a new medical assistant trying to manage my time. Do you recommend setting aside specific parts of the day to work on prior authorizations? Or does your office squeeze them in where they can?
“I would recommend setting aside a specific part of the day to work on prior authorizations. This ensures that PAs are completed in a timely manner and minimizes disruptions to the workflow during that time. Our pharmacy technician who submits PAs generally does so first thing in the morning before the AM clinic session gets started and providers begin approaching her with questions.” – Toni M. Zahorian, PharmD, BCACP
Documenting Decisions in the EHR
I am a fan of vedolizumab but it seems to be the biologic that gets questioned most often. Do you have any tips for pre-empting that?
“I would point out that the FDA approved vedolizumab for moderate to severe ulcerative colitis and Crohn’s disease, but did not require that the patient fail an anti-TNF before approving vedolizumab. The AGA Clinical Care Pathway position vedolizumab equally with anti-TNFs as first line treatment for UC and CD. Similarly, the ACG CD Guideline has recommended vedolizumab as first line treatment for CD. I would refer to these position papers in your PA and/or appeal for a denial.” – Francis A. Farraye, MD, MSc
What do you think will happen with tofacitinib? Because it is an oral, do you think that it will be easier to get PA through?
“We will have to see if insurance companies will position tofacitinib relative to the biologics for moderate to severe ulcerative colitis. The PI for tofacitinib doesn’t require failure of an anti-TNF or vedolizumab and therefore is appropriate choice as first line therapy for moderate to severe UC.” – Francis A. Farraye, MD, MSc
Do you prescribe anything for patients while they are waiting for prior authorization (steroids, for example)?
“Every patient is different so it’s hard to make a blanket recommendation. If the patient is sick, a short course of prednisone or budesonide is often prescribed. Efforts are underway by national and local GI societies to mandate insurance companies respond to a PA or request for appeal within 2-3 business days.” – Francis A. Farraye, MD, MSc
Appeals Process
I always seem to get a retired physician for my peer-to-peer reviews and it is very frustrating. Can you provide some strategies that have been effective in being assigned someone that has experience and knowledge about IBD?
“When requesting a peer to peer, specifically ask to speak with a gastroenterologist given the complex nature of managing IBD. If the request is denied, ask the insurance expert his or her name and specialty. Be firm but courteous and make your case. If the insurance clinician approves your request, thank them and specifically ask for them when dealing with PAs for this insurance company. If the clinician denies your request, explain that you are very disappointed and state that you feel the case be decided by a gastroenterologist and request to speak with one as you feel strongly that your request is the best option for the patient.” – Francis A. Farraye, MD, MSc
When you use the electronic PA system, does it allow you to save your information so that you have it for the files?
“Yes, when using Navinet (via CoverMyMeds) all PA submissions are saved and can be viewed upon login. If your username is provided by the institution, you may also have access to view previous PA submissions from anyone linked within the same institution. This is helpful when taking over for someone who has changed positions or when sharing responsibilities among a group.” – Toni M. Zahorian, PharmD, BCACP
In slide 12 about appeals, it talks about escalating the process through different levels. How long do you usually wait before moving to the next level of appeal?
“There is no correct answer. The sicker the patient, the shorter the time I am willing to wait. I would send repeated faxes, email, or calls every two days explaining the severe nature of the patient’s illness.” – Toni M. Zahorian, PharmD, BCACP
Have you had any luck with the state Department of Insurance?
“I would say we are highly successful with Medicaid in Massachusetts. If a PA is denied, Mass Health will request additional submissions including clarifying information, but does not allow for appeals. However, they do allow for peer-to-peer reviews if needed.” – Toni M. Zahorian, PharmD, BCACP
Patient Resources
I really liked the information video for patients about keeping up with insurance. I think it will be helpful information to send home with them.
“We are gratified to hear that you found the material useful. Our goal was to offer practical approaches to dealing with the PA process.” – Francis A. Farraye, MD, MSc
Don’t see your question here? Submit one to be answered by our faculty!
Clinical Decision-Making in Ulcerative Colitis: Considerations for Improved Outcomes
Join this CME Outfitters mobile case series designed to test your knowledge, confidence, and performance in optimizing treatment for patients with UC. The AGA has developed an evidence-based UC Care Pathway to guide treatment decisions for moderate- to high-risk patients; yet, in clinical practice, many clinicians are not integrating this pathway into their decision-making.
Participate Now!Fact or Fiction? Sorting Out Common Misconceptions About Ulcerative Colitis to Improve Patient Care
It’s time to separate fact from fiction. We invite you to join this Crohn’s and Colitis CongressTM enduring activity as faculty use gaming and case studies to debunk many misconceptions about UC and provide evidence and best practices to pave the way for better patient outcomes.
Deep Remission, Top-Down Treatment Strategies and Real-World Data in Patients with UC: An Interactive and Innovative Case Series
In this CME Outfitters symposium, expert faculty will guide learners through patient cases using an interactive infographic to explain the importance of initiating early targeted biologic therapy and provide evidence-based strategies to take action to achieve sustained remission and long-term clinical outcomes.
Deep Remission, Mucosal Healing, and Top-Down Treatment Strategies in Ulcerative Colitis: An Infographic Journey
This CME Outfitters interactive infographic explains the importance of initiating early targeted biologic therapy and provides evidence-based strategies to take action to achieve sustained remission and long-term clinical outcomes.