CMS has directed all Medicare Administrative Contractors (MACs) to implement a temporary claims hold:

  • This standard practice is typically up to 10 business days and ensures that Medicare payments are accurate and consistent with statutory requirement
  • The hold prevents the need for reprocessing large volumes of claims should Congress act after the statutory expiration date and should have a minimal impact on providers due to the 14-day payment floor
  • Providers may continue to submit claims during this period, but payment will not be released until the hold is lifted

The Telehealth Situation

Coverage for certain services was at risk prior to the government shutdown. Now many are in limbo.

Effective Dates Medical Mental/Behavioral Health, RHCs, & FQHCs
During the

Public Health Emergency (PHE)

 Originating site restrictions were waived allowing patients to be seen via telehealth from their own homes
Made Permanent/ Expiring PHE flexibilities for telehealth were extended briefly but expire on September 30, 2025 The Consolidated Appropriations Act, 2021 permanently removed geographic and place of service restrictions for behavioral health telehealth services. Beneficiaries, including those in both rural and urban areas, can receive behavioral health telehealth services in their homes. Two-way, interactive, audio-only technology is permitted for behavioral health telehealth services
CURRENT LIMBO PERIOD DURING GOVERNMENT SHUTDOWN
Beginning 10/1/25

Unless Extended

 Most services provided to beneficiaries in their homes and outside of rural areas and hospice recertifications will be prohibited via telehealth
Beginning 1/1/2026

 

 An in-person visit within six months of an initial Medicare behavioral/ mental telehealth service, and annually thereafter, is for mental health services furnished via communication technology to beneficiaries in their homes will be required.

Special Note for ACOs: “CMS notes that the Bipartisan Budget Act of 2018 allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restriction and in the beneficiary’s home. There is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers. Clinicians in applicable ACOs can provide these covered telehealth services and bill Medicare for the telehealth services that are permissible under Medicare rules during CY 2025, irrespective of further Congressional action” – MGMA Shutdown Update

 

ACO’s & Telehealth

https://www.cms.gov/files/document/telehealth-faq-04-09-25.pdf

 

What special telehealth flexibility applies to Accountable Care Organizations (ACOs)?

The Bipartisan Budget Act of 2018 (BBA) added section 1899(l) to the Social Security Act, which provides certain ACOs the ability to expand the use of telehealth. There is now special coverage for telehealth services furnished on or after January 1, 2020, to prospectively assigned beneficiaries, by physicians and other practitioners participating in a Medicare Shared Savings Program (Shared Savings Program) ACO that is under two-sided risk and that has selected prospective assignment. Specifically, these new policies:

  • Remove the geographic limitations imposed under normal fee-for-service (FFS) rules AND
  • Allow a beneficiary to receive many telehealth services from their home Q2

Who can provide these services?

All physicians and practitioners who furnish and get payment for covered telehealth services (subject to State law) and who bill through the TIN of an ACO participant in an applicable ACO can provide and get payment for covered telehealth services under this new flexibility. Starting January 1, 2020, applicable ACOs are those with prospective assignment for a performance year in the ENHANCED track (including existing Track 3 ACOs), BASIC track levels C, D, or E, or in the Track 1+ Model.

Risk-based ACOs that participate under the preliminary prospective assignment with retrospective reconciliation method do not meet the definition of an applicable ACO, because final assignment is not performed until after the end of the performance year. Clinicians in these ACOs and those in non-risk based ACOs may provide telehealth services subject to the usual Medicare FFS rules.

 

Next Steps from Industry Experts

Taya Gordon, CEO

Atlas & Perpetua Healthcare

 “Coordinate a team meeting and transparently discuss with your staff so they are  aware of how to schedule your patients and empowered to educate your community. This is going to impact your revenue cycle and your front desk is your first line of defense” – Taya
Doral Jacobsen, CEO

Prosper Beyond

 “Connect with your commercial payer reps and discuss how this can or will impact your Managed Medicaid and/or Medicare Advantage patients” – Doral
Jill Arena, CEO

HealthePractices

 “Now is the time to consider your financial contingency plans, figure out how you’re going to meet your financial obligations if the shutdown goes on for any significant length of time” – Jill
Kem Tolliver, CEO

Medical Revenue Cycle Specialists

 “If you elect to use an ABN to continue seeing Medicare patients via telehealth during this limbo period, remember the burden of proving medical necessity will fall on the clinic if telehealth is not extended when the government resumes” – Kem
Anne Hirsch, MD

HealthePractices

 “Ensure that your documentation adequately supports medical necessity in the event that those services are challenged” – Anne

Resources