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LUGPA Policy Update: CMS Partially Lifts Claims Hold Amid Government Shutdown and Expired Medicare Provisions

On October 21, 2025, in response to the ongoing government shutdown and the expiration of key Medicare legislative payment provisions under the Full-Year Continuing Appropriations and Extensions the Centers for Medicare & Medicaid Services (CMS) has partially lifted its claims hold for certain services Act, 2025 (Pub. L. 119-4, Mar. 15, 2025), .

CMS has instructed all Medicare Administrative Contractors (MACs) to process claims with dates of service (DOS) on or after October 1, 2025, for:

  • Services paid under the Medicare Physician Fee Schedule (PFS)
  • Ground ambulance transport claims
  • Federally Qualified Health Center (FQHC) claims
  • Telehealth claims that CMS confirms are definitively for behavioral and mental health services

However, CMS has directed MACs to continue temporarily holding:

  • Other telehealth services not confirmed as behavioral or mental health
  • Acute Hospital Care at Home claims

This partial lift addresses payments for services affected by the lapse, as CMS awaits potential Congressional action to renew key provisions. Providers, including urology practices, are encouraged to continue submitting eligible claims and can expect payment for lifted categories—though delays may persist due to the broader shutdown context. The extended hold, now beyond the typical two-week window, is raising concerns about cash flow disruptions for Medicare fee-for-service revenues.

Affected Claims and Services

Claims with Lifted Hold (Process and Pay):

  • All claims under the Medicare Physician Fee Schedule (PFS)
  • Ground ambulance transport claims
  • FQHC claims
  • Telehealth claims confirmed by CMS as behavioral or mental health

Claims Still on Hold:

  • Other telehealth services not confirmed as behavioral or mental health
  • Acute Hospital Care at Home claims

Submission Guidance:
Providers should continue submitting claims for categories where the hold has been lifted. Payments will proceed as CMS resumes processing but may be delayed. For held claims, providers should anticipate continued payment disruptions until further guidance or Congressional action.

Telehealth-Specific Impacts (Absent Congressional Action)

As of October 1, 2025, many statutory limitations on Medicare telehealth services that were waived during the COVID-19 Public Health Emergency have now resumed for services not related to behavioral or mental health. These include:

  • Prohibitions on services provided to beneficiaries in their homes or outside rural areas
  • Requirements for in-person, face-to-face encounters for hospice recertifications

Urology providers relying on telehealth for follow-up care or consultations may face coverage denials without additional legislative extensions.

Recommendations for Practitioners

  • Advance Beneficiary Notice (ABN):
    In the absence of Congressional action, practitioners offering non-covered telehealth services should consider issuing an ABN to notify beneficiaries of potential out-of-pocket costs.
  • Monitor and Hold Claims:
    Continue monitoring Congressional developments and CMS guidance. Providers may choose to hold claims for non-behavioral telehealth services until coverage is restored.
  • ACO Exception:
    Under the Bipartisan Budget Act of 2018 (Pub. L. 115-123), clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) may continue providing and receiving payment for certain covered telehealth services without geographic restrictions and in patients’ homes. No special approval is required.

Broader Context: Shutdown and Legislative Outlook

The partial claims lift comes amid ongoing budget negotiations and uncertainty over full-year appropriations.

  • ACA Open Enrollment: The 2026 enrollment period begins November 1, with premium hikes fueling partisan debate over tax credit extensions.
  • Administrative Strain: OMB has warned that over 10,000 federal employees could face reductions-in-force (RIFs), while disputes over back pay for furloughed workers continue to stall negotiations.
  • Economic Ripple Effects: Military pay has been temporarily maintained through redirected DOD funds, but civilian employees—including air traffic controllers and congressional staff—are missing paychecks, exacerbating operational challenges nationwide.

These conditions heighten the urgency for Congress to pass extensions stabilizing Medicare payments and telehealth coverage.

Action Items for LUGPA Members

  1. Submit and Expect Processing for Lifted Claims: Continue filing PFS, ambulance, FQHC, and behavioral/mental health telehealth claims for DOS ≥ October 1, 2025.
  2. Pause High-Risk Submissions: Hold non-behavioral telehealth and Hospital-at-Home claims until coverage is reinstated.
  3. Communicate with Patients: Use ABNs to inform beneficiaries of potential non-coverage for restricted telehealth services.
  4. Track Federal Developments: Follow CMS and Congressional updates closely and advocate for timely Medicare extensions through LUGPA’s advocacy channels.
  5. Leverage ACO Flexibilities: ACO-participating practices can continue offering covered telehealth services under existing statutory authority.
  6. Plan for Delays: Prepare for continued cash flow challenges and coordinate with MACs for claim-specific guidance.

LUGPA will continue to monitor these developments and provide timely updates as Congressional action progresses. This situation underscores the vulnerabilities in Medicare funding during budget disputes and the ongoing need for stable, predictable payment reform.

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