August 27, 2026

In the latest issue of The Rheum Advocate, learn about recent progress on Capitol Hill, the ACR’s response to a CMS proposal that could threaten access to rheumatology care, and key state advocacy developments. Plus, explore member-only letter templates designed to help strengthen insurance coverage and reimbursement.

Good News from Capitol Hill for Researchers

The Senate recently passed a bipartisan continuing resolution (CR) that would fund the federal government through December 11. Importantly, this CR includes a provision that temporarily blocks implementation of the Office of Management and Budget’s (OMB) proposed federal grants rule. The ACR strongly opposes this proposal, and we have urged Congress to intervene. Now, we need your help.

The House version of the CR does not currently include this language. Before your lawmakers return from the August recess, please take a moment to help ensure they understand how critical this provision is to the rheumatology community. With just a few clicks through the ACR Legislative Action Center, you can join our efforts.

ACR Fights CMS Proposal That Threatens Access to Rheumatology Care

The ACR along with its coalition partners is actively advocating against a Center for Medicare and Medicaid Services (CMS) proposal to reduce payment for same-day services billed with modifier -25. If finalized, this policy could jeopardize patient access to rheumatology care by imposing additional financial strain on independent rheumatology practices already facing significant challenges.

The ACR has joined the Same Day Care Coalition, a broad alliance of national physician and patient organizations representing primary care clinicians, medical and surgical specialists, and the patients they serve. The coalition has met with key stakeholders on Capitol Hill and is actively seeking a congressional champion for a Dear Colleague letter.

The ACR is also engaging directly with CMS, the Office of Management and Budget, and other federal agencies alongside our Same Day Care Coalition partners. Our advocacy emphasizes that the proposal is not supported by clinical data or evidence showing that Medicare is overpaying for these same-day services.

In addition, the ACR signed onto an American Medical Association-led letter highlighting the policy’s unfair impact on office-based physicians. The College is also developing a rheumatology-specific sign-on letter to underscore the consequence of reduced payments for rheumatology practices and the additional barriers it could create for rural patients seeking specialty care.

The ACR’s formal comments on the proposed 2027 Medicare Physician Fee Schedule will further detail our opposition to the policy and its potential impact on people with rheumatic diseases nationwide.

How You Can Help

You can make your voice heard! Explain how this harmful policy could affect patient access to rheumatic disease care and place an undue financial burden on already struggling independent rheumatology practices.

• Urge CMS to Rescind Their Misguided Modifier -25 Policy
• Urge Congress to Stop CMS’ Misguided Modifier -25 Policy

State Advocacy Roundtable Highlights: Downcoding, Medicaid Work Requirements, and Payer Accountability

The American Medical Association’s (AMA) recent State Advocacy Roundtable highlighted emerging state-level strategies with significant implications for rheumatology practices and patients. Discussions centered on Medicaid work requirement exemptions, administrative burden, downcoding, prior authorization, and broader efforts to hold health plans accountable for policies that disrupt patient care.

Navigating Medicaid Work Requirements and Coverage Protections

Roundtable discussions focused on how medical societies can prepare for the Medicaid work requirements established in H.R. 1. Participants emphasized three key priorities:

• Establishing Exemption Lists: Medical societies must work directly with state agencies to define comprehensive chronic disease and condition lists to ensure patients with complex, disabling rheumatic conditions qualify for necessary work requirement exemptions and coverage protections.
• Streamlining Attestations: States should minimize administrative friction by adopting universal attestation forms that allow clinical staff to assist in completing documentation, rather than requiring physicians to manually oversee every submission.
• Proactive Patient Navigation: Practices and professional societies must prepare patients for shifting eligibility and coverage rules, helping them navigate redeterminations, utilization management hurdles, and potential coverage disruptions.

States Target Downcoding and Unilateral Payment Cuts

Payer downcoding practices are facing heightened scrutiny in state legislatures, with states deploying differing approaches. Illinois and Indiana were both offered as case studies:

• Illinois: Lawmakers enacted protections requiring health plans to use current coding guidelines and evaluate the complete medical record before reducing a code. The law also bars insurers from discriminating against clinicians who care for high-acuity, medically complex populations.
• Indiana: Legislation established a uniform coding dispute appeals process and placed strict guardrails on clawbacks, requiring at least 60 days notice to physicians and capping retroactive recoupments at 180 days.

These legislative models offer effective counters to automated, retrospective payment policies that shift administrative and financial risk onto practices. However, a model for downcoding legislation has not been fully realized.

Ohio’s Multi-Bill Legislative Strategy

Ohio advocates used a unique strategic approach to payer accountability legislation. Rather than pursuing a single omnibus package, which had been defeated in years past, advocates introduced 10 standalone bills targeting distinct payer practices.

This compartmentalized strategy prevented insurers from concentrating opposition against a single bill while highlighting the full scope of health plan abuses for lawmakers. Two bills have been signed into law, while measures addressing prior authorization and mid-year formulary changes remain under consideration. For societies facing pushback against omnibus reforms, breaking priorities into targeted proposals might offer an effective pathway forward.

Implications for Rheumatology Advocacy

States continue to serve as essential testing grounds for payer reform. Whether limiting downcoding, establishing standard appeals, curbing retroactive recoupments, or reforming prior authorization, these case studies provide useful frameworks for rheumatology advocates nationwide.

As administrative hurdles grow more complex, proactive state advocacy remains vital to safeguarding practice sustainability and patient access. The ACR will continue collaborating with state rheumatology societies and medical associations to advance legislation that benefits rheumatology practices and patients.

Strengthen Insurance Coverage and Reimbursement with Member-Only Letter Templates

Get ready-to-use letter templates that help support appropriate coverage and reimbursement for rheumatology care. These member-only resources can streamline prior authorizations and appeals, save valuable time, and help you communicate more effectively with health plans.

Explore the templates >

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