Streamlining Rheumatology Peer-to-Peer Scheduling for Biologics and Infusions

The Unique Challenges of Rheumatology P2P Reviews

Rheumatology prior authorization is heavily concentrated in high-cost biologics (e.g., Humira, Enbrel, Stelara, Skyrizi, Rinvoq) and JAK inhibitors, alongside infusion therapies. Initial denials are common due to complex step therapy requirements, biosimilar mandates, or specific documentation gaps, frequently necessitating a peer-to-peer (P2P) review. The manual process of scheduling these calls, reconciling clinician calendars, and preparing documentation creates significant bottlenecks, contributing to clinician burnout and delaying patient access to vital treatments.

Common Triggers for Rheumatology Peer-to-Peer Reviews

• Failure to document specific prior conventional DMARD trials (e.g., methotrexate) as per ACR Treatment Guidelines.
• Payer mandates for biosimilar substitution not met, leading to brand biologic denial.
• Incomplete disease activity assessment documentation (e.g., missing DAS28, CDAI, PASI, or BASDAI scores).
• Gaps in required pre-initiation screening documentation (e.g., TB, hepatitis B/C, immunization status).
• Requests for off-indication biologic use without sufficient supporting payer policy or clinical literature.
• Step therapy requirements for specific TNF inhibitors or JAK inhibitors not clearly met.

Klivira's Automated Approach to Rheumatology P2P Scheduling

Klivira's platform automates the entire peer-to-peer scheduling workflow, integrating seamlessly with EMRs and payer systems. Our denial-router intelligently identifies P2P-eligible cases, such as clinical-necessity disagreements for biologics, and initiates the automated scheduling process. This reduces administrative burden for PA coordinators and ensures rheumatologists can engage in these critical discussions more efficiently, accelerating patient access to care for chronic autoimmune conditions.

Core Automation Features for Rheumatology P2P

• **Clinician Calendar Integration:** Klivira reads rheumatologists' calendars via FHIR Appointment resources or integrated systems like Outlook/Google Calendar to find optimal P2P call times.
• **Payer-Side Window Discovery:** The platform ingests payer-published P2P availability or initiates requests via payer portals/secure messaging to capture offered windows.
• **Automated Pre-Call Packet Assembly:** Klivira leverages FHIR to pull relevant clinical notes, prior-line therapy history, lab/imaging results, and applicable peer-reviewed literature into a structured packet for the clinician.
• **Intelligent Reminders:** Automated reminders with the pre-call packet are sent to both the clinician and coordinator, ensuring preparedness.
• **Structured Outcome Capture:** Post-call outcomes (approval, modification, upheld denial) are captured via a structured form and written back to the EMR as FHIR DocumentReference and Communication resources.
• **P2P Pattern Analytics:** Klivira provides insights into P2P success rates by denial reason, payer, and clinician, informing upstream PA submission improvements.

Integrating with Rheumatology Clinical Guidelines and Workflows

Klivira's policy logic is designed to be ACR Treatment Guideline-aware, incorporating specific criteria such as the 2010 ACR/EULAR criteria for RA, CASPAR criteria for PsA, and modified New York/ASAS criteria for AS. This ensures that pre-call documentation packets are clinically relevant and support the rheumatologist's discussion with the payer's medical director, particularly for complex biologic step therapy and biosimilar substitution requirements. The platform also accounts for the variability of medical versus pharmacy benefit for the same agent, a common complexity in rheumatology.

Mitigating Clinician Burden and Expediting Patient Care

Manual peer-to-peer scheduling is a significant contributor to clinician burnout, as highlighted by AMA surveys. Klivira addresses critical failure modes by automating calendar reconciliation, eliminating three-way scheduling friction, and ensuring comprehensive pre-call documentation. While Klivira cannot eliminate the clinician's time on the call, it significantly reduces the administrative overhead, allowing rheumatologists to focus on clinical decision-making and patient care, ultimately expediting patient access to necessary biologic and infusion therapies.