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Limited Medicare claims hold due to government shutdown
The Centers for Medicare & Medicaid Services (CMS) instructed all Medicare Administrative Contractors (MACs) to continue to temporarily hold Medicare claims for services provided on or after Oct. 1, 2025, that are impacted by the expired Medicare legislative payment provisions, including telehealth services other than for behavioral or mental health care, and services provided in locations with a work geographic practice cost index (GPCI) below the 1.0 floor. For all other services, Medicare claims will continue to be processed and paid in a timely manner.
Telehealth services, except for behavioral health services, are limited to rural areas as they were before the COVID public health emergency, and patients cannot receive telehealth services in their home. CMS notes that physicians who choose to perform telehealth services that are not payable by Medicare on or after Oct. 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN). When MACs stop holding claims, if the government does not reopen and make the previous telehealth policies retroactive to the beginning of the shutdown and the MACs therefore deny the claims, physicians will be able to charge patients who signed ABNs directly. Physicians may also choose to hold claims associated with telehealth services. Additionally, certain Medicare Shared Savings Program accountable care organizations (ACOs) may continue to receive payment (PDF) for covered telehealth services to certain Medicare beneficiaries without geographic restriction and in the beneficiary’s home. CMS has updated its telehealth FAQs (PDF).
In addition, the ability to provide audio-only services to Medicare patients lapsed, as did the Acute Hospital Care at Home program. Funding extensions for community health centers, the National Health Service Corps, and teaching health centers that operate graduate medical education (GME) programs expired on Sept. 30, 2025. The 1.0 work GPCI floor extension expired on Oct. 1, 2025. Additional programs that were funded through the end of the previous continuing resolution and have now lapsed include: special diabetes programs; public health emergency authorities (e.g., Public Health Emergency Fund); increased inpatient hospital payment adjustment for certain low-volume hospitals; Medicare-Dependent Hospital (MDH) program; quality measure endorsement, input, and selection; and outreach and assistance for low-income programs (e.g., area agencies on aging).
The AMA is monitoring delays in Medicare claims processing and other Medicare payment problems, including during the shutdown. Physicians and medical practice staff who experience hardship or other issues related to this claims hold are asked to inform AMA advocacy staff of these problems by emailing [email protected] and including the subject heading “Medicare Payment Delay.”
