CY 2026 MPFS Proposed Rule: Office-Based Rheumatology Practices Anticipate Pay Boost | | |
Rheumatologists are projected to see an overall 4% increase in total allowed charges under CMS’s proposed CY 2026 Medicare Physician Fee Schedule (PFS), released July 14. However, impacts vary by site of service: office-based rheumatologists are expected to see a 6% increase, while those billing primarily in facility settings may face a 12% decrease. These changes are primarily driven by CMS’s proposed revisions to the practice expense methodology.
The rule also marks the first year CMS would implement dual conversion factors under MACRA: $33.5875 for Qualifying APM Participants and $33.4209 for non-QPs. These reflect MACRA’s statutory updates (i.e., 0.75% and 0.25% respectively), a +0.55% budget neutrality adjustment due to a proposed “efficiency adjustment,” and a temporary 2.5% increase authorized under the One Big Beautiful Bill Act. Service-level payment rates are available in Addendum B using the applicable conversion factor.
Specific to drugs, CMS proposes changes to how average sales price (ASP) is calculated, including clarifications around price concessions and bona fide service fees, and clarifies that maximum fair prices (MFPs) established as part of the Medicare Drug Price Negotiation Program would be factored into ASPs. Finally, as part of its broader “Make America Healthy Again” initiative, CMS seeks input on strategies to strengthen chronic disease prevention and management.
| CSRO on Capitol Hill: Leadership Advocates for Rheumatology Issues at the Alliance of Specialty Medicine Fly-In | |
CSRO President, Dr. Aaron Broadwell, and Vice President of Advocacy & Government Affairs, Dr. Madelaine Feldman, (pictured left) represented CSRO at the Alliance of Specialty Medicine’s Annual Fly-In, a three-day advocacy conference held in Washington, D.C. CSRO is a founding member of the Alliance of Specialty Medicine, a coalition of 15 national medical societies representing over 100,000 specialty physicians committed to advancing policy priorities to improve patient access to quality specialty care.
On the second day of the conference, Drs. Broadwell and Feldman held meetings on Capitol Hill with the offices of House Speaker Mike Johnson, Rep. Steve Scalise, Sen. Bill Cassidy, MD, and Sen. John Kennedy. They discussed the Alliance’s legislative priorities, including reforms to prior authorization, stabilizing Medicare physician payments, regulating Medicare Advantage upcoding by insurers, and increasing investment in graduate medical education. Throughout the conference, CSRO leaders and attendees heard directly from healthcare leaders, including FDA Martin Makary, MD, and several Members of Congress, about current political dynamics and issues impacting the healthcare industry.
| | Business of Rheumatology Seminar: Staffing Rheumatology Practices | | |
Join CSRO on Wednesday, August 20, at 7pm CT / 8pm ET for our next Business of Rheumatology seminar focusing on staffing rheumatology practices!
The program will bring together perspectives from different practice settings to discuss the current staffing challenges facing private practices and strategies for how they can be addressed. Our expert panel features:
- Adrienne Hollander, MD – Arthritis, Rheumatic & Bone Disease Associates
- Tien-I Karleen Su, MD – Amicus Arthritis and Osteoporosis Center
- Moderator: Firas Kassab, MD – South Charlotte Rheumatology
| | CSRO Comments: Indiscriminate Downcoding by Aetna and Cigna | | |
CSRO recently sent correspondence to Aetna and Cigna regarding their indiscriminate downcoding of Level 4 and 5 Evaluation & Management (E&M) visits, sometimes without notifying providers, resulting in significant reimbursement cuts and administrative burdens. These policies ignore clinical realities, rely on flawed algorithmic review processes, and demand excessive documentation, all of which jeopardize patient access and strain medical practices.
CSRO vehemently opposes these unfair practices and urges all providers to contact Aetna and Cigna to demand transparency, fairness, and a halt to these damaging policies.
| | Limited Space Remaining: Register for CSRO's Advocacy Conference | |
Join CSRO this September 12-13 in Dallas, Texas, for our annual Advocacy Conference! This free event offers the opportunity to connect with others in the rheumatology community, hear from policy experts, and stay informed on the issues shaping our field.
Visit the event webpage to view our program and learn more. Space is limited and the room block is filling up fast – sign up now to secure your spot!
| | Partner Spotlight: Rheumatology Access Network | | |
Support your access team by sending them to the Rheumatology Access Network (RAN) Conference, happening October 4–6 in Nashville, TN. This unique event features an agenda covering every aspect of patient access, including appeals, prior auths, denials, buy-and-bill, Medicare, biosimilars, and optimizing physician-staff collaboration.
Attendees will receive directional insight to improve patient outcomes, streamline office operations, and access exclusive resources, including a comprehensive Access Handbook available only at the conference. Travel scholarships are available to help cover expenses, making this a high-value opportunity for your staff. Access Staff can apply here: STEP Scholarship
Additionally, physicians who send team members will receive an invitation to a virtual, physician-only summit focused on practice efficiency and revenue optimization.
Empower your team with the tools and knowledge to better serve your patients and enhance your practice.
Learn more about the agenda and conference at rheumatologyaccess.com.
| | Legislation Around the Country | AK: Prior Authorization Reform Legislation Becomes Law | | |
After passing the Alaska Senate and House, Senate Bill 133, prior authorization reform legislation, was enacted by the legislature without the Governor’s signature on July 15. In April, CSRO pledged its early support for the bill that would streamline the prior authorization process by removing unnecessary burdens on physician practices, thereby allowing patients timely access to essential medications. The new law promotes transparency and sets clear utilization requirements for health plans and utilization review entities. It requires that health plans respond to routine prior authorization requests within 72 hours and to urgent requests within 24 hours.
CSRO is an active member of the State Access to Innovative Medicines (SAIM) Coalition and regularly collaborates with partners in dedicated working groups to strategize on advancing similar prior authorization and step therapy reform bills in other state legislatures for the 2025 and upcoming 2026 sessions.
| CSRO’s 340B Reform Principles Highlighted During iCAN Panel Discussion | |
On July 16, Dr. Erin Arnold, CSRO Board Member and Advocacy Co-Chair of the Chicago Rheumatism Society, represented CSRO on a panel discussion hosted by the International Cancer Advocacy Network (iCAN) on policies influencing the 340B Drug Pricing Program. Dr. Arnold provided a physician’s perspective on the panel, focusing her remarks on how the 340B program has deviated from its original purpose and played a significant role in healthcare consolidation, which is threatening private physician practices, including rheumatology practices.
Dr. Arnold outlined the existing problems with the 340B program and the CSRO’s main 340B policy principles to ensure that safety net providers and the patients they care for can continue to access the discounted drugs intended for them.
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Want to learn more about the legislation introduced in your state? Visit CSRO’s Map Tool to find all of the new and enacted bills within CSRO’s policy priorities.
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What's Happening in the States
CSRO tracks legislative activity relevant to the rheumatology community and their patients. Check out the list below to see the status of CSRO priority bills from the past two weeks, and click here to view a full status report of CSRO priority bills.
| 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. | | |
AK
- Prior Authorization | Step Therapy (SB133): Enacted w/o Governor Signature (07/14/2025)
CA
- 340B Drug Pricing Program (AB1460): In committee: Hearing postponed by committee.
- PBM Reform (SB41): Read second time and amended. Re-referred to Committee on Appropriations
- Prior Authorization (AB512): Read second time and amended. Re-referred to Committee on Appropriations
MA
- Prior Authorization (SB1403): Hearing scheduled for 07/15/2025 from 10:00 AM-04:00 PM in Gardner Auditorium
| | Mark Your Calendar: Upcoming Events
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Virtual Advocacy Day: October 8, 2025
Save the date to advocate alongside CSRO as we host live conversations with health care leaders. Be notified when registration launches by clicking here!
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Action Center
Use CSRO's convenient online platform to easily find out who your elected officials are and engage with them directly.
Advocacy Council
Amplify your voice by assembling with other like-minded individuals to enhance CSRO’s advocacy initiatives.
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.
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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.
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