Nov. 14, 2025: National Advocacy Update

Unpaid Medicare telehealth claims status remains uncertain

Even though the government has reopened and reinstated Medicare flexibilities for telehealth services, the status of many telehealth service claims submitted since Oct. 1, 2025, when the shutdown began, remains uncertain. On Nov. 7, the Centers for Medicare & Medicaid Services (CMS) released an update indicating that it has been difficult for Medicare Administrative Contractors (MACs) to determine if certain claims for telehealth services were payable during the shutdown or not.

Specifically, claims that contractors could clearly determine were for patients treated for mental or behavioral health conditions were considered payable, but other telehealth claims were being held. The Nov. 7 release said that, instead of continuing to hold them, MACs would start returning the unpaid telehealth claims to the practices that submitted them. The claims could then be resubmitted for payment with additional documentation establishing that the service is for a mental or behavioral health condition or be resubmitted after the government reopens and broader telehealth coverage is reinstated. 

As the U.S. Senate voted on legislation that would end the government shutdown on the first business day after CMS’ announcement, it is unclear whether the MACs returned the held claims to the submitters or not. Now that the shutdown has ended, the AMA expects that CMS will clarify how any unpaid claims for telehealth services provided during the shutdown period will be handled. The AMA will keep physicians informed about Medicare’s telehealth payment policies. 

CMS releases list of WISeR model technology vendors

CMS has released the list of technology vendors participating in its Wasteful and Inappropriate Service Reduction (WISeR) Model and their associated Medicare Administrative Contractors (MACs). Under the WISeR Model, physicians in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington will be required to exchange claims and prior authorization data with the technology vendor contracted by their MAC, which will use artificial intelligence tools to identify potentially wasteful or inappropriate services.   

The AMA previously urged CMS to make this list public as soon as possible to help practices and health IT vendors prepare for WISeR implementation. CMS has now released the list of WISeR Model MACs and technology vendors, along with their assigned regions, to assist physicians and EHR developers in planning for the Model start date in January 2026. WISeR Model MACs and technology vendors can be found on the CMS website. The AMA recommends that physicians contact their medical practices’ health IT and EHR vendors promptly to confirm they can support the data exchange and workflow requirements necessary for WISeR participation. 

Trump administration announces deal on GLP-1 pricing and coverage

On Nov. 6, President Trump announced that his administration had reached agreement with drug manufacturers Novo Nordisk and Eli Lilly to significantly reduce the price of glucagon-like peptide-1 (GLP-1) drugs for treatment of obesity. The announcement also noted a change in CMS policy that will allow for coverage of GLP-1 medications for treatment of obesity for some Medicare and Medicaid patients. The agreement comes at a time of surging demand, high prices and limited insurance coverage for GLP-1 drugs when used for weight loss.  

Under the terms of the agreement, Novo Nordisk and Eli Lilly have agreed to offer their blockbuster drugs Ozempic, Wegovy, and Zepbound at rates as low as $350/month through the newly created TrumpRx platform. The TrumpRx platform will connect cash pay patients directly with the manufacturer direct-to-consumer programs, who will then assist patients in accessing the drugs at the TrumpRx prices. The GLP-1 products are expected to be available to patients through TrumpRx sometime in 2026.  

The administration also announced that CMS would for the first time provide coverage for these drugs when used for treatment of obesity in certain patients. These drugs will be available to patients with a co-pay of $50. Additionally, CMS announced the Generating Cost Reductions for U.S. Medicaid (GENEROUS) Model, a new Center for Medicare and Medicaid Innovation (CMMI) model that allows Medicaid programs to purchase participating drugs at the same prices aligned with those paid in other countries.  

The AMA applauded the move to lower the price of the previously high-priced drugs. Lowering the cost of prescription drugs continues to be an AMA priority. 

AMA joins efforts to oppose changes to Toxic Substances Control Act

The AMA joined 10 health and medical organizations in signing a comment letter (PDF) opposing the Environmental Protection Agency’s (EPA’s) changes related to procedures for chemical risk evaluation under the Toxic Substances Control Act (TSCA). The comment letter asks the EPA to withdraw this proposal, as it could weaken protections from deadly chemicals and TSCA risk evaluation. These changes would underestimate real health risks and reduce protections for workers and communities already burdened by pollution.  

The letter describes how exposure to harmful industrial and commercial chemicals poses significant risks to human health, and how these substances can affect nearly every organ system. Harmful chemicals such as volatile organic compounds, flame retardants, and plasticizers are linked to respiratory diseases like asthma and chronic obstructive pulmonary disorder (COPD), cardiovascular problems, developmental disorders in children, and increased cancer risk. Both acute and chronic exposure can exacerbate existing health conditions and contribute to premature death.  

EPA’s proposal seeks to reverse its existing policy and allow for consideration of alternative control measures when determining whether a chemical presents an unreasonable risk under TSCA. Our joint letter asked for TSCA chemical risk evaluation to be grounded in the best available science to inform the most health-protective safeguards on the chemicals in our lives every day. The letter concludes by stating that fully implementing TSCA is a critical piece in safeguarding public health from harmful chemicals, as protecting human health requires comprehensive exposure prevention. 

Medical societies urge repeal of new Anthem out-of-network policy

Over 90 medical societies sent a letter (PDF) this week to Elevance Health President and CEO Gail Boudreaux, urging repeal of a policy that will reduce payment to participating hospitals when out-of-network physicians are used to provide patient care.  

Under the Facility Administrative Policy: Use of a Nonparticipating Care Provider (PDF), being rolled out in 11 states starting Jan. 1, 2026, Anthem Blue Cross and Blue Shield plans, under Elevance Health, will begin penalizing hospitals with a 10% reimbursement cut when out-of-network physicians are used in the provision of care, and may be terminating hospitals from Anthem networks for continued use of nonparticipating physicians.  

The medical societies expressed concern that the policy essentially circumvents the balance established under the No Suprises Act and highlighted the harm this policy will have on patient access and the stability of independent physician practices. Rather than such a punitive policy, the letter suggests policies that incentivize physician participation in Anthem’s networks such as fair contracts, reduced administrative burdens, prompt payment, and network adequacy requirements.   

More articles in this issue

• Nov. 14, 2025: Advocacy Update spotlight on government shutdown ending
• Nov. 14, 2025: State Advocacy Update