August 13, 2026

This issue of The Rheum Advocate highlights urgent legislative and regulatory developments affecting rheumatology, along with practical guidance to help strengthen your practice. Explore opportunities to take action, navigate policy and reimbursement changes, and advance advocacy for rheumatology patients and professionals.

While Congress Is Home, Speak Up for Rheumatology Patients!

August recess is the several week period each summer when Congress leaves Washington and members return to their home states and districts for what’s officially called a “district work period.” Members of Congress are out of session in DC and in district, meeting constituents, doing site visits, holding town halls, and preparing for the fall legislative work (including appropriations). They are expected to gather input, hear local concerns, and stay visible at home.

This August Recess, take a few moments to advocate from home. The ACR’s Legislative Action Center makes it easy to contact policymakers with just a few clicks. Check out a few of our most popular campaigns and make your voice heard today!

Defend Patient Access & Clinical Autonomy: Stop Restrictions on IV Orencia

Regional Medicare restrictions on physician-administered IV Orencia (abatacept), like those taking place at CGS (a Medicare Administrative Contractor), threaten continuity of care and strip patients of vital treatment pathways.

• Urge CGS to Stop Restrictions on IV Orencia
• Urge CMS to Protect Patient Access to IV Orencia
• Tell Congress: Patient Access to IV Orencia Is at Risk

Urge Congress to Reform Medicare Physician Reimbursement

• Stabilize reimbursement to protect patient access to complex rheumatology therapies
• To preserve access to care, Congress must repair Medicare’s broken payment system

Ensure Patient Access to Treatments

• Protect patients from soaring out-of-pocket costs
• Make pharmacy benefit managers transparent & accountable

ACR Raises Concerns About Medicaid Work Requirement Rule

The ACR submitted comments in response to the Center for Medicare and Medicaid Services (CMS) interim final rule on Medicaid work requirements, specifically highlighting the burden the medical frailty exemption process would place on physicians, enrollees and state Medicaid agencies.

To qualify for a medical exemption from the work requirement under the interim rule, Medicaid applicants and current enrollees must demonstrate not only that they have a qualifying diagnosis, but also that their condition prevents them from working 80 hours a month. However, there is no universally accepted clinical measure that reliably determines a person's ability to work. Functional capacity also varies significantly depending on the type of work performed and for chronic diseases, like rheumatoid arthritis and lupus, can fluctuate episodically. The ACR urges CMS to develop an exemption process that instead considers the severity of a patient's condition, functional limitations, treatment burden, and episodic periods of incapacity.

The interim rule, as it stands would effectively impose an unfunded administrative mandate on physicians, requiring them to make medical frailty determinations with limited guidance. The rule could also result in harmful care disruptions, particularly for individuals with chronic rheumatic diseases. For rheumatology patients who receive complex or high-cost therapies, including biologics, infused medications, and specialty pharmacy treatments, for example, interruptions in these therapies, even for a short duration, could lead to disease progression, loss of treatment efficacy, and increased long-term healthcare costs.

Medicare Physician Fee Schedule Changes for FY 2027: Modifier 25 and Other Code Changes May Seriously Impact Practice of Rheumatology

The FY 2027 Medicare Physician Fee Schedule proposed by CMS includes a 1.68% payment cut for physicians and a major change to CPT modifier 25, which could result in significant changes to reimbursement for core rheumatology services, such as infusion therapies. Specifically, the proposed rule would slash payments for 0, 10 and 90-day global services provided on the same day and in the same location as an E/M visit. The less expensive service would be paid at 50%, while only the more expensive service would receive full reimbursement. Though CMS rationalizes this change by claiming that it would reduce overpayments, in reality, it will result in greater inefficiencies, by providing physicians incentives to schedule E/M visits and global services on different days. This will also result in new barriers to care for patients.

Other changes in the proposed FY 2027 fee schedule include new restrictions on use of remote monitoring codes, changes in the calculation of practice expense methodology and a shift in calculation of how E/M visit complexity is reimbursed. To take grassroots action with the ACR to protect physicians from pay cuts, consult our Legislative Action Center messages.

Strengthen Your Practice with Free Access to the Business Side of Rheumatology Practice Guide

ACR members can access the Business Side of Rheumatology Practice Guide at no cost through August 31 with the code “Member Discount BOM.” This 100+-page manual offers practical tools, resources, and strategies to help you navigate the business and operational challenges of rheumatology practice.

Access the guide >

Planning for ACR Convergence 2026? Learn how to add the Practice Innovation Summit to your meeting experience.

Having trouble downloading the PDF? Try clearing your browser cache. Workplace or institutional network firewalls may also block downloads; contact your IT department for assistance if needed.

TPE Audits: What Rheumatology Practices Need to Know

Medicare audits increasingly extend beyond coding accuracy. For rheumatology practices administering high-cost therapies—especially infused biologics—Medicare Administrative Contractors (MACs) are closely reviewing whether the medical record clearly supports medical necessity.

CMS’s Targeted Probe and Educate (TPE) program is its primary medical-review initiative. MACs use billing data to identify providers, services, or items with higher claim-error rates or unusual billing patterns, then review a sample of claims—typically 20 to 40—and provide individualized education and feedback. Continued documentation or billing concerns can lead to additional oversight, including prepayment review or other audit actions.

While TPE is intended to be educational, an audit can create substantial administrative burden and jeopardize payment when documentation is incomplete. Reviewers look beyond diagnosis codes to determine whether the record explains:

• Why a specific therapy was selected
• Why it remains medically necessary
• The patient’s disease severity and current symptoms
• Prior therapies and treatment response
• The clinical rationale for continuing treatment

Many TPE findings do not reflect inappropriate care; rather, the record may not clearly tell the patient’s clinical story. Documentation that is adequate for day-to-day care may still lack the detail needed to support a claim during a medical review.

Consistency across physician notes, infusion records, treatment plans, diagnosis coding, and billing documentation is essential. Missing or conflicting details can create avoidable vulnerabilities, as auditors can assess only what is documented—not what was discussed but never recorded. Regular internal chart reviews can help identify gaps before they result in denials or audit findings.

As CMS continues to emphasize program integrity and claim accuracy, TPE reviews will remain an important part of Medicare oversight. Practices that prioritize complete, consistent, patient-centered documentation will be better positioned to demonstrate medical necessity, protect patient access to treatment, and navigate audits successfully.

The ACR Practice Department offers free auditing resources to members to help practices prepare for potential reviews. If your practice is undergoing a TPE review or would like to assess its documentation readiness, contact the ACR auditors at practice@rheumatology.org.

Launch Your Advocacy Journey with the Young Advocates Division!

Calling all residents, FITs, and early career rheumatologists! The Young Advocates Division (YAD) of advocates is tailored to residents, fellows in training, and rheumatologists and rheumatology professionals who have been in practice for less than 10 years. Participating in YAD is a great opportunity to engage with the ACR's advocacy efforts early on in your career. Members of the YAD will be given opportunities to meet with their lawmakers, author LTEs and op-eds, and other advocacy efforts to support the rheumatology community. Sign up today to be the first to know when an ACR advocacy opportunity arises in your area!

AWIR and ACR Team Up to Advance Rheumatology Advocacy!

The ACR attended the Association of Women in Rheumatology’s (AWIR) Annual Meeting in Orlando, Florida earlier this summer. ACR and AWIR staff presented an advocacy update to attendees alongside Drs. Gwen Melton and Stephanie Ott. Attendees received a detailed overview of the ACR’s congressional and regulatory advocacy and learned more about how AWIR and the ACR regularly collaborate to help advance the rheumatology profession.

FDA Requires New Safety Warning for Denosumab-bnht for Patients with Advanced CKD

The FDA has required Fresenius Kabi USA, LLC to distribute new safety information about Denosumab-bnht (CONEXXENCE) due to an increased risk of severe, potentially fatal hypocalcemia in patients with advanced chronic kidney disease (eGFR < 30 mL/min/1.73 m²), including dialysis-dependent patients and those with CKD-mineral bone disorder (CKD-MBD). Before prescribing Denosumab-bnht to patients with advanced CKD, rheumatologists should evaluate for CKD-MBD (including iPTH, serum calcium, 25(OH) vitamin D, 1,25(OH)₂ vitamin D), consider bone turnover assessment, monitor serum calcium weekly for the first month and monthly thereafter, and coordinate care with clinicians experienced in CKD-MBD.

Provide each patient with the CONEXXENCE Patient Guide, review the risk of severe hypocalcemia and its symptoms, and advise them to seek prompt medical attention if concerning signs occur.

For full safety information, clinicians should consult the Prescribing Information and REMS (Risk Evaluation and Mitigation Strategy) materials available on the CONEXXENCE REMS website, and report adverse reactions to Fresenius Kabi Vigilance at 1-800-551-7176 or via FDA MedWatch.