July 16, 2026

From federal advocacy and Medicare coverage to state policy changes, patient access, and clinical guidance, this issue of The Rheum Advocate delivers a comprehensive look at the latest developments affecting rheumatology. Explore key legislative updates, advocacy opportunities, member benefits, and new ACR recommendations to help you stay informed and engaged.

Act Now to Protect Federal Funding for Biomedical Research!

The Office of Management and Budget (OMB) released proposed guidance in early June that would drastically increase federal review requirements for grant funding decisions, including decisions related to funding for biomedical research at the National Institutes of Health (NIH). The new guidance would make it easier for senior political appointees to arbitrarily suspend grants mid-award, with no advance notice or opportunity for appeal and would also require enhanced pre-issuance review of grant decisions by political appointees, to ensure compatibility of research projects with presidential priorities.

The guidance also makes certain costs crucial to translating research into clinical practice (i.e., publication costs, conference attendance and association membership costs) unallowable under federal grant terms, except in special cases and limits the ability of researchers to collaborate with peers in other countries.

Take action on this rule and protect the integrity of rheumatology research using the ACR’s Legislative Action Center →

Don’t Miss These Exclusive ACR Member Discounts for Rheumatologists in Private Practice!

Make the most of your ACR membership with valuable, limited-time resources designed to help you strengthen your practice, support your team, and plan confidently for the future. These member opportunities are available for a limited time only, so be sure to take advantage before the August deadlines.

Get Complimentary Access to the Business of Rheumatology Manual

Whether you are launching a new practice, expanding services, or looking for ways to improve day-to-day operations, the Business of Rheumatology manual is a practical resource to help you move forward with confidence. This comprehensive guide covers essential areas such as practice operations, financial management, staffing, and service expansion, with topics including:

• In-office infusion services
• Ancillary implementation
• Human resource management
• Optimizing APPs in rheumatology practice

Now through August 31, 2026, ACR members can access the manual at no cost using the discount code: “Member Discount BOM” at checkout. After August 31, the manual will be available for purchase at regular member pricing ($499).

Download your complimentary copy today before this member benefit expires →

Save with Early-Bird Registration for the Practice Innovation Summit

Ready to take your practice to the next level? Join rheumatology leaders and colleagues in Orlando, November 6–7, for the Practice Innovation Summit. This event will feature practical strategies, expert insights, and forward-looking solutions to help strengthen independent and community-based rheumatology practice.

Early-bird registration ends August 24, 2026. Register now to secure the discounted rate before it expires.

Take advantage of these exclusive member opportunities while they are available. Strengthen your practice, support your team, and position your organization for long-term success. For questions or additional information, contact the ACR practice management team at practice@rheumatology.org.

Nearly 600 Letters to Congress Drive Momentum on Part B Drug Access

A joint ACR and Coalition of State Rheumatology Organizations (CSRO) grassroots campaign, encouraged 428 rheumatologists from across the country to send 597 letters to their members of Congress urging them to protect patient access to Medicare Part B drugs. These efforts are already paying off with additional co-sponsors being added to the bipartisan Protecting Patient Access to Cancer and Complex Therapies Act (H.R. 4299) legislation every day!

Add your voice using the ACR's Legislative Action Center →

Federal Policy Updates Signal Major Impacts for Rheumatology Practice and Research

This summer has brought a wave of federal regulatory activity with potentially significant implications for rheumatology care, research, and those in private practice. The ACR is actively engaging with policymakers on several key proposals to help ensure patient access as well as protecting the research pipeline and reducing administrative burden.

Prior Authorization Reform Moves Forward

In June, the ACR submitted comments in response to the Centers for Medicare and Medicaid Services (CMS) proposed transparency and accountability requirements for prior authorization of prescription drugs. The College expressed support for shorter decision timeframes and new public reporting requirements, both of which aim to improve access to timely care.

However, the ACR urged CMS to strengthen the proposal by expanding its applicability to additional payers, including Medicare Part D plans and state-based exchange plans. The ACR also recommended more detailed, disaggregated reporting to better identify patterns of delay and denial that affect patient care.

Research Funding Oversight Raises Concerns

The ACR is also preparing comments on expansive new guidance from the Office of Management and Budget (OMB) regarding federal research funding oversight. The proposal would allow for mid-year termination of grant awards without notice or appeal for political reasons, require senior political review prior to grant issuance, and restrict certain costs such as publication and conference participation.

The ACR is highlighting the potential downstream effects on rheumatology research, including disruptions to ongoing studies, reduced collaboration, and broader risks to the U.S. research enterprise and global competitiveness. Members interested in weighing in can take action through the ACR's Legislative Action Center. (See first story for more.)

Medicaid Work Requirements Pose Clinical Challenges

In collaboration with the Arthritis Foundation, the ACR is responding to a new Interim Final Rule implementing Medicaid work and community engagement requirements for expansion populations. States must begin implementation by the end of 2026.

A central concern is the rule’s open-ended definition of “medical frailty,” which determines eligibility for exemption. The ACR is emphasizing the practical challenges this ambiguity creates for clinicians, who may be responsible for documenting and verifying frailty status without clear, standardized criteria.

Looking Ahead: Medicare Physician Fee Schedule

The ACR is actively analyzing the recently released CY 2027 Medicare Physician Fee Schedule proposed rule and will share detailed summaries and advocacy priorities with members in the coming weeks. Key areas of focus include proposed changes to conversion factors and work RVUs, practice expense methodology updates, and policies that impact access to and reimbursement for rheumatology and pediatric rheumatology care. The ACR will engage with CMS throughout the comment period to protect practice sustainability and ensure Medicare policies support high-quality, patient‑centered rheumatology care.

Read the press release →

RheumPAC Invests in Key Races Across the Country to Shape a Pro-Rheumatology Congress

RheumPAC’s second quarter disbursement strategy was focused on making key investments in challenger races while also maintaining strong support for our incumbent champions. We also made sure to show early, strong support by becoming Founding Investors in the Democratic Doctor’s PAC, founded to support pro-physician candidates running for office on the Democratic ticket. If you haven’t made your 2026 investment.

Support RheumPAC today →

Wisconsin’s 3rd Congressional District

In the first quarter of this year, the RheumPAC Committee voted to support Rebecca Cooke, who is running in Wisconsin’s 3rd Congressional District. Rebecca has outraised her opponent, Derrick Van Orden thus far this cycle. She has raised nearly $6.5 million to Van Orden’s $5.6 million, giving her more than a $600k cash on hand advantage. Polling from earlier this spring has her with a 1-point lead over Van Orden. With strong name recognition across the district, a proven grassroots fundraising base, and a political environment increasingly favorable to Democrats, Cooke is well positioned to win in November.

California’s 6th Congressional District

Dr. Richard Pan is running in California’s 6th Congressional District. A pediatrician and state legislator, Dr. Pan has both a deep understanding of health care policy and roots in the district. Of note, he led the charge on groundbreaking vaccine legislation that upped vaccination rates and helped end a measles outbreak in California. Dr. Pan finished second in the district’s June 2nd primary and will face formerly Republican, now Independent Rep. Kevin Kiley in November. Dr. Pan’s candidacy is also supported by many other major physician organizations, including the American Academy of Neurology and the American Society of Anesthesiologists. We will continue to monitor the race and provide updates as the landscape evolves.

Pennsylvania’s 10th Congressional District

Lastly, the RheumPAC Committee voted to support Janelle Stelson running in Pennsylvania’s 10th Congressional District against incumbent Rep. Scott Perry. Stelson won her primary election handily earlier this year and her campaign has released internal polling that shows her up 6 points on the incumbent. Stelson has served as a newscaster in the district for over 30 years and has high name recognition and favorability ratings. She also narrowly lost to Rep. Perry in 2024 in one of the closest races in the country. Her campaign is also supported by many other medical organizations, including the American College of Emergency Physicians.

States Crack Down on Downcoding and AI Denials

State legislatures remain active in 2026, advancing critical legislation designed to improve transparency, strengthen patient protections, and alleviate the administrative burdens for practices. While the ACR tracked hundreds of healthcare-related bills, several newly enacted measures represent landmark progress on our advocacy priorities.

Downcoding Reform Gains Traction

One of the year's most significant successes has been the accelerating legislative momentum against insurer downcoding practices. Downcoding—the practice where a health plan unilaterally changes a provider’s billed service to a lower-paying code—directly threatens practice sustainability and undermines clinical autonomy.

• Arkansas HB 1287: The law establishes a statutory definition of downcoding and establishes a strict 340-day transparency window. Health plans are now required to notify a healthcare provider within 30 days of processing a claim if it has been downcoded, clearly explaining reason to ensure fair appeal practices.
• Virginia HB 484: The law prohibits health insurance carriers from using automated claims-editing software to systematically downcode evaluation and management (E&M) services unless the system reflects correct coding standards and considers all patient data submitted by the provider. Crucially, the law requires that any disputed downcoding decisions be reviewed and adjudicated by a natural person, rather than an automated algorithm.
• Illinois SB 3114: Most recently, Illinois lawmakers sent a robust downcoding bill to the governor for signature. The bill would prohibit automated downcoding using algorithms or automated tools, mandates human review of downcoding determinations, prevents diagnosis-only downcoding, and prevents discriminatory targeting of patients with chronic conditions.

Regulating Automated Prior Authorizations and AI Denials

While downcoding measures combat arbitrary fee reductions, there is a broader legislative effort to target the systemic friction of the prior authorization process itself. In 2026, states have aggressively moved to restrict insurers from utilizing automated algorithms to quietly delay or deny necessary care.

• Iowa HF 2635: This comprehensive legislation establishes strict standards for health carriers and utilization review organizations. While the law permits payers to use artificial intelligence (AI) and automated algorithms for initial screening, it explicitly prohibits AI from being the sole basis for denying, delaying, or downgrading a request for medically necessary care. It also mandates that any adverse determination must be made by a qualified medical professional practicing in the same or similar specialty as the requesting physician, and forces utilization reviewers to complete prepayment audits within 45 days.
• Utah SB 319: The law enacts sweeping transparency mandates on insurance carriers, adding strict statutory timelines and reporting metrics to standard utilization review workflows to reduce processing delays.
• New Hampshire HB 1554: This law is designed to eliminate "ghost reviewers." The legislation establishes a mandatory, structured peer-to-peer review mechanism at any stage of the utilization review timeline, allowing treating physicians to demand a direct conversational exchange with an insurer's medical director or clinical peer. Crucially, the bill forces insurance companies to explicitly disclose the reviewing provider’s full name, medical license type, issuing state, and National Provider Identifier (NPI) before the consultation can occur.

States Expand PBM Oversight

Pharmacy Benefit Managers (PBMs) faced continued legislative scrutiny in 2026, driven by bipartisan concern over rising prescription drug costs and anti-competitive steering practices that impact specialty fields like rheumatology.

• Florida HB 697: This bill prohibits PBMs from reimbursing non-affiliated pharmacies at lower rates than their own vertically integrated, PBM-affiliated pharmacies, increasing patient access to prescriptions.
• Virginia HB 830: This bill requires 100% of any rebates and discounts to be passed through to the health plan and strengthens regulatory oversight of PBMs.

Looking Ahead

The legislative milestones achieved in 2026 reflect a growing awareness among state policymakers of the compounding administrative and financial pressures facing medical practices. The ACR will continue to collaborate with state rheumatology societies, patient coalitions, and policymakers to advance policies that protect practices and patients. However, we cannot do it alone.

Find out more about how to be involved in advocacy →

CGS Policies Threatening Medicare Coverage for IV Orencia, Jeopardizing Patient Access to Treatment and Practice Viability

CGS Medicare, a company that serves as a Medicare Administrative Contractor (MAC) for the Centers for Medicare & Medicaid Services (CMS) for Medicare Jurisdiction 15 (Kentucky and Ohio), has implemented a change related to the office administered formulation of Orencia (abatacept), effectively establishing a new step-therapy requirement that forces practices to justify why patients cannot use subcutaneous Orencia before receiving IV therapy. This change is already disrupting established treatment and jeopardizing patient access to medically appropriate care.

As we continue gathering information to better understand the impact of this policy and to inform advocacy, input and experiences from practices will be invaluable. We encourage practices and clinicians to reach out to us directly with any questions, support needs, or to share and discuss reimbursement challenges and denials related to these changes by writing to practice@rheumatology.org.

ACR Releases 2026 Updated Recommendations for Disease Classification and Response Criteria Development

The ACR has released the 2026 Updated Recommended Methods for Development of Disease Classification and Response Criteria, providing a comprehensive framework to guide researchers and clinicians in this critical area of rheumatology.

The updated document outlines key methodological approaches for developing disease classification and response criteria, grounded in current best practices and informed by evolving scientific standards. It highlights core guiding principles, offers practical examples, and details important considerations for projects seeking ACR funding or endorsement.

These recommendations are designed to promote consistency, transparency, and scientific rigor across criteria development efforts. They also reflect the increasing complexity of rheumatic diseases and the need for standardized, data-driven approaches to support research, clinical trials, and patient care.

By incorporating updated methodologies and real-world considerations, the guidance serves as a valuable resource for investigators designing studies, developing outcome measures, or refining disease definitions. It also reinforces ACR’s commitment to advancing high-quality research that ultimately improves diagnosis, treatment, and outcomes for patients with rheumatic diseases.

Explore the full recommendations to better understand how these updated methods can support your work in classification and response criteria development.