All Eyes on Telehealth as Federal Shutdown Continues

EDITOR’S NOTE

Day 3 of the federal shutdown continues. This article by Mark Spivey is part of a special section today published by RACmonitor and ICD10monitor called The Lowdown on the Shutdown.

The first casualty of the federal government shutdown could very well be the widespread provision of telehealth that began shortly following the advent of the COVID-19 pandemic.

“Absent Congressional action, beginning October 1, 2025, many of the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 Public Health Emergency will take effect again for services that are not behavioral and mental health services,” a MLN Connects post issued earlier this week read. “These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas and hospice recertifications that require a face-to-face encounter. In some cases, these restrictions can impact requirements for meeting continued eligibility for other Medicare benefits.”

While Medicare and Medicaid coverage is generally expected to continue amid the shutdown – albeit with a few hitches – telehealth was impacted immediately. Providers are now unsure whether such services delivered during the remainder of the shutdown will be reimbursed retroactively, with some reportedly avoiding submitting claims on such services until there’s meaningful movement on the issue.

“In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage,” the MLN Connects post advised. “Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are not payable by Medicare in the absence of Congressional action.”

Use of telehealth skyrocketed 63-fold for Medicare fee-for-service beneficiaries during the height of the COVID pandemic, in 2020, according to statistics maintained by the U.S. Department of Health and Human Services (HHS). A total of 95 percent of Health Resources and Services Administration (HRSA)-funded health centers used telehealth to provide at least some primary care last year, when a quarter of Medicare users took advantage of at least one service via telehealth.

The Centers for Medicare & Medicaid Services (CMS) this week directed all Medicare Administrative Contractors (MACs) to implement a temporary claims hold, calling it a “standard practice” that typically lasts up to 10 business days and ensures that Medicare payments “are accurate and consistent with statutory requirements.” 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,” officials added, noting that providers may continue to submit claims during this period, but payment will not be released until the hold is lifted.

CMS further noted 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, with 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,” officials added. Mark Spivey is a national correspondent for RACmonitor and ICD10monitor who has been writing and editing material about the federal oversight of American healthcare for nearly 20 years. He can be reached at mcspivey33@gmail.com.