CMS Implements Telehealth Claims Hold Amid Government Shutdown, Affecting Medicare Services

What's Happening?

The Centers for Medicare and Medicaid Services (CMS) has issued guidance on Medicare billing and telehealth services due to the government shutdown. As pandemic-era telehealth flexibilities have ended, CMS directed Medicare Administrative Contractors to implement a temporary 10-day hold on telehealth claims starting October 1, 2025. This measure aims to prevent the reprocessing of claims if Congress reinstates the flexibilities. Providers can submit claims during this period but will not receive payment. Pre-pandemic rules require Medicare beneficiaries to be in rural health clinics or hospitals for telehealth visits, excluding mental health services. Audio-only visits are no longer permitted, and certain practitioners like occupational therapists and audiologists can no longer render telehealth services. CMS advises providers to issue an Advance Beneficiary Notice of Noncoverage for services not covered by Medicare.

Why It's Important?

The government shutdown's impact on healthcare services, particularly telehealth, is significant as it disrupts access for millions of Medicare patients. The temporary claims hold by CMS is a strategic move to manage administrative burdens during this period. However, the lapse in telehealth coverage marks a regression in healthcare services, affecting patient access and continuity of care. Stakeholders like the American Telemedicine Association emphasize the need for Congressional action to restore telehealth flexibilities and ensure retroactive reimbursement. The shutdown also affects staffing at the Department of Health and Human Services, with 32,460 employees furloughed, potentially leading to administrative delays in healthcare program payments.

What's Next?

The CMS guidance suggests that providers should monitor Congressional actions closely and consider holding telehealth claims until further notice. The Alliance for Connected Care and other healthcare stakeholders are urging Congress to act swiftly to restore telehealth flexibilities and address the administrative challenges posed by the shutdown. The Department of Health and Human Services will continue essential functions like emergency preparedness and medical reviews, but the shutdown's duration remains uncertain, with potential long-term impacts on healthcare services and research activities.

Beyond the Headlines

The shutdown highlights broader issues in U.S. healthcare policy, including the reliance on government funding for essential services and the vulnerability of healthcare access during political impasses. The lapse in telehealth coverage underscores the need for sustainable policy solutions that ensure continuity of care regardless of political circumstances. The situation also raises ethical concerns about the impact on vulnerable populations who depend on government-supported healthcare services.