GAFP and PeachState Collaborate to Enhance Primary Care for Patients with Inflammatory Bowel Disease

A new change in PeachState’s review process will allow coverage for family physicians and other primary care specialists to order Remicade for Inflammatory Bowel Disease (IBD). Peach State initiated this policy change in response to the collaborative initiative with the Georgia Academy of Family Physicians that began in August 2015.  Discussions between Peach State and GAFP originated from a report received from a GAFP physician member where a denial for coverage resulted in a patient hospitalization.  The denial for Remicade treatment was based primarily on the Centene/Peach State policy that emphasized physicians’ specialty in the determination of medical necessity.  The policy at that time required a gastroenterologist or colorectal specialist to be the ordering physician.  Upon review, PeachState and the Georgia Academy agreed that inflammatory bowel treatments fall within the purview of family medicine and other primary care specialties, who are capable of meeting other factors in the determination of medical necessity, including tissue biopsy diagnosis.  Peach State implemented this change in review process this January.  The Georgia Academy would like to thank Peach State for their continued efforts in supporting family medicine to improve the quality of care for the communities we serve.