From the Nation’s Capital

CSRO, Same Day Care Coalition Push Back on Modifier -25 Proposal

The Same Day Care Coalition, of which CSRO is a member, will soon meet with the Centers for Medicare and Medicaid Services (CMS), the Office of Management and Budget (OMB), and the White House Domestic Policy Council (DPC) to oppose the Modifier -25 proposal in the CY 2027 Medicare Physician Fee Schedule. Under the proposal, when a separately identifiable office or outpatient E/M service is furnished on the same day as a procedure with a 0-, 10-, or 90-day global period, CMS would pay the highest-valued service at 100 percent and reduce payment for the other service by 50 percent. The Coalition, made up of organizations representing a broad range of physician specialties, medical group practices, and patients, is urging CMS not to finalize the proposal.

CSRO also launched a grassroots campaign this week giving rheumatologists an opportunity to urge policymakers to oppose the proposal. Please follow the instructions in the action alert below and make your voice heard.

Update on IV Orencia in the CGS Jurisdiction

On August 14, CSRO received confirmation from senior staff in the Centers for Medicare and Medicaid Services (CMS) Administrator’s Office that the agency had reviewed concerns raised by CSRO regarding Medicare coverage of IV Orencia (abatacept). Following CMS engagement, CGS revised its J0129 Orencia Educational Fact Sheet, removing the previous requirement that providers demonstrate why a patient could not receive self-administered subcutaneous Orencia, including the prior three-month “trial” requirement.

Yesterday, CGS confirmed with CSRO that Part B Medical Review will re-review denied claims from the Targeted Probe and Educate (TPE) in 2026 for medical necessity based on the revised J0129 Orencia Fact Sheet. Upon completion of the claim re-reviews, including appeals results, CGS will re-evaluate each provider’s status in the TPE program, including error rates and potential progression into the next round of the TPE process. Providers will be notified via End of Round Results Letters. In addition, based on CGS’s clarification that all reviews will be conducted for medical necessity using the revised fact sheet, CSRO expects that claims currently in appeals will also be considered using the revised fact sheet.

While these developments represent important progress, CSRO will continue working with CMS and CGS to monitor implementation and address any remaining issues for practices with TPE audits, appeals, or other claims affected by the prior policy. Please continue to share any challenges you encounter, as well as successful appeal outcomes, with CSRO.

Across the States

CA: CSRO Calls on California Lawmakers to Prioritize Patient Protections

Earlier this month, CSRO joined comments led by the All Copays Count Coalition to the Assembly Health Committee, opposing recent changes to SB 1199, a copay accumulator adjustment ban bill, that weakened patient protections in the underlying legislation. Among the changes the Coalition opposed was expanding the bill's "generic exclusion" provision to include biologics and interchangeable biosimilars—meaning patients could be forced to switch to a potentially less effective drug simply to avoid a copay accumulator adjustment program. The amended bill also introduced new loopholes allowing payers and PBMs to impose additional administrative burdens on patients seeking copay assistance. While the Coalition couldn't restore the bill to its original version, the payer-backed version ultimately failed to advance out of the Assembly Appropriations Committee this month.

OR: CSRO Weighs In on PDAB's Drug Reviews of Skyrizi and Tremfya

Ahead of the Oregon Prescription Drug Affordability Board's (PDAB) August 19th meeting, CSRO submitted comments outlining concerns about the Board's drug reviews of Skyrizi and Tremfya. CSRO cautioned that PDAB policy can target the wrong problem: reducing payer reimbursement while leaving patients' cost-sharing obligations unchanged. The Coalition called on the PDAB, during its drug reviews, to get to the root of the problem — which requires looking at multiple factors, such as insurance benefit design, list price, and failures to pass rebates and discounts directly to patients.

In reviewing both Skyrizi and Tremfya, CSRO urged the PDAB to recognize that not all therapeutic alternatives are therapeutically equivalent, and that only alternatives that are true therapeutic equivalents to Skyrizi and Tremfya should be considered clinically appropriate for substitution. Finally, while Oregon does not currently have upper payment limit (UPL) authority, the state continues to explore authorizing it for drug reviews. CSRO strongly cautioned against UPL authority, noting that intended savings do not automatically flow directly to patients.

What's Happening in the States

Interested in learning more about CSRO’s engagement in the states? Visit our State Legislation Correspondence page to review the letters submitted to state legislatures on CSRO’s priority issues.

Click above to access CSRO’s new State Legislative Tracker to find the status of CSRO’s priority legislation affecting the rheumatology community and its patients at the state level.

Business of Rheumatology Seminar Series - Building a Clinical Research Program in Community Rheumatology Practice: September 16, 2026

Join us for the September Business of Rheumatology webinar as we discuss how practices can successfully engage in clinical research to improve patient care and support practice growth. This session is part of our ongoing webinar series, with support from Johnson & Johnson.

Register here!

Advocacy Conference: October 2-3, 2026

Join us in Washington, D.C. for CSRO’s flagship Advocacy Conference to learn, network, and strategize around patient access to care. Register here.

Business of Rheumatology Seminar Series - Smart Payer Contracting and Transparency in Coverage: December 2, 2026

Join us for our December Business of Rheumatology webinar to learn how to navigate payer contract negotiations with confidence. This session is part of our ongoing webinar series, generously supported by Johnson & Johnson.

Register here!

Fellows Conference: March 19-20, 2027

Calling all rheumatology fellows! Mark your calendars to join us in San Antonio, TX , for the CSRO annual Fellows Conference.

Sign up for the Registration Launch here!

State Society Conferences:

CSRO's state rheumatology society members host their own annual meetings throughout the year. Find a listing of these state-specific conferences on our website.

Action Center

Use CSRO's convenient online platform to easily find out who your elected officials are and engage with them directly.

Career Center

Locate the perfect fit whether you're looking for new career opportunities or trying to find the right candidate.

Explanatory Statement: “Underwater” Biosimilars

To aid in addressing the issue of "underwater" biosimilars with payers, CSRO has created a document to illustrate the extent of the problem.

Legislative Map Tool

Find your state on our interactive map tool to learn about current or proposed policy and ways you can take action to make an impact.

Payer Issues Reporting Form

Request assistance with any payer relation issues that may be impacting your patients or office.

Policy Correspondence

Easily access all of CSRO’s policy letters submitted to payers, state, and federal governments as an informational resource.

Rheum for Action

Learn about the latest advocacy issues in CSRO's advocacy column authored by Dr. Madelaine Feldman and produced in partnership with Medscape.

Step Therapy Cover Sheets

Review CSRO's state-specific step therapy materials that help guide practices in gaining an exemption from step therapy protocols.

Questions?

Please visit the CSRO website for other news and updates, and do not hesitate to contact us with any questions at info@csro.info.