This article, featuring Martie Ross, PYA Kansas City Office Managing Principal and Director of PYA’s Center for Rural Health Advancement, was originally published by Part B News.
Like previous federal government shutdowns, the one that ensued when Congress failed to produce a continuing resolution (CR) on the budget by Oct. 1 has implications for providers. You should reduce the chances of harm by planning to address them now.
The current shutdown is the tenth such shutdown since 1980, triggered by failure to legislate a budget agreement for the fiscal year that begins annually on Oct. 1, and always followed by a period of political maneuvering for advantage prior to a compromise.
The record for shutdown length, established in 2018, is 35 days. No one knows how long this one will last, but Paul Werner of the Buttaci, Leardi and Werner law firm in Princeton, N.J., believes “the growing political divide in the country makes it harder for people to reach compromise.” Rhetoric on the shutdown has been hot; President Trump has threatened to illegally withhold back pay from furloughed government workers as a consequence, and Werner notes that Rep. Jared Golden (D-Maine), the only Democrat to vote for a Republican-sponsored budget plan, immediately received a primary challenge.
Nonetheless Werner believes this shutdown will end “without too much tortuous delay.”
Take note of CMS’ limited guidance
But CMS has already alerted providers to related issues. For one, while essential functions are supposed to be preserved in a shutdown, departments are obliged to furlough employees deemed non-essential, which can slow up processes.
CMS has issued little guidance on this. An Oct. 1 memo from CMS’ Quality, Safety & Oversight Group (QSOG) and Survey & Operations Group (SOG) describes how “State Survey & Certification Activities” operate under the shutdown. Essentially, says Martie Ross, office managing principal for the PYA consultancy in Kansas City and director of the PYA Center for Rural Health Advancement, the memo says “we’ll follow up on outstanding work plans, and we’ll do immediate jeopardy audit reviews, but that’s it [for now].”
On the same date, the agency issued an update that went out to Medicare Learning Network (MLN) subscribers and was later posted at Medicare administrative contractor (MAC) sites, explaining what would happen with claims processing under the shutdown and the Medicare telehealth flexibilities, which also ended on Oct. 1. (The failure to get these flexibilities included in a CR is part of what torpedoed the budget process.)
Aside from that, CMS hasn’t said much, and Daniel A. Cody, a health care and life sciences attorney with the Mintz firm in San Francisco and New York, doesn’t expect much more guidance.
“Notwithstanding the provider industry’s eagerness to get more detailed guidance from CMS,” he says, “the realistic side of me thinks that, given the fact that certainly many HHS and CMS employees have been furloughed, I think it’s probably unlikely that we’re going to get additional written guidance, at least in the short term.”
In its payments guidance, CMS says “standard practice” for a claims hold “is typically up to 10 business days and ensures that Medicare payments are accurate and consistent with statutory requirements,” and should have a “minimal impact” on providers due to the 14-day payment floor, which is the minimum time MACs can hold payments in any case.
“Medicare is a trust fund; the money’s there,” Ross says. “CMS can pull down from that and pay the claims to the contractors. There’s some issue, as there always is in every shutdown, about whether they’ll pay the MACs. But Medicare [provider payment] is separate.”
“Providers may continue to submit claims during this period,” CMS adds, “but payment will not be released until the hold is lifted.” For that reason, Cody says, providers should probably hang onto their claims until the shutdown blows over, so that they don’t “overwhelm” contractors and cause them to make mistakes, such as issuing duplicate payments, which could make a bigger mess than if they got the claims later, when things calm down.
Then there are the telehealth flexibilities, which removed originating and distant site requirements for most telehealth coverage during the COVID-19 public health emergency, and have been extended ever since, becoming a popular treatment mode among Medicare beneficiaries (PBN 9/29/25). CMS suggests that providers collect advance beneficiary notices of noncoverage (ABN) from any patients receiving the services as modified. That way, if the services remain uncovered due to an extended shutdown — or because whatever legislation ends the shutdown does not include a re-upof the flexibilities — the patient will have been lawfully notified that they’re on the hook for the cost of the treatment.
Many observers believe Congress will eventually bring back the telehealth flexibilities, and that they’ll make it retroactive to cover the shutdown period, which may be why CMS also says providers “may choose to hold claims associated with telehealth services that are not payable by Medicare in the absence of Congressional action.”
3 Steps to Take
Notify and assist your telehealth patients.
Cody thinks it makes sense for providers “to identify patients who have upcoming telehealth appointments that are impacted,” notify them of the shutdown issue, and work with them on solutions. “Providers obviously have a professional obligation to provide continuity of care,” he adds.
It may be that some of your patients are dual-eligibles and you can refer them to covered telehealth under state Medicaid programs that haven’t been touched by the shutdown, Cody says. Also, he adds, “to the extent providers have the ability to identify qualified originating sites that are convenient for patients, they can assist the patients in finding those originating sites and finding transportation services.”
Be mindful of other shutdown-affected services.
Some Medicare hospital and home care programs went out of coverage when the last budget expired and may or may not come back. For example, Ross says, the Acute Hospital Care at Home (AHCAH) waiver that’s been available to beneficiaries since 2020 is now out of coverage. (“For all hospitals with active AHCAH waivers,” CMS has told providers, “all inpatients must be discharged or returned to the hospital on September 30, 2025, in the absence of Congressional action to extend the initiative.”) Also, some Medicaid programs have suffered billions in funding cuts with the shutdown; patients won’t feel the cuts now, but if the funds are not restored they might lose some access next year.
Alexander Salerno, M.D., founder of the Nirvana Healthcare network serving over 75,000 patients in New Jersey, reminds you that the shutdown furloughs fall especially hard on entities that accommodate underserved communities such as federally qualified heath centers (FQHC) and rural health clinics (RHC) that “rely heavily on federal and state funding and subsidies to cover staffing, medical supplies and clinician salaries. As federal grants and reimbursements are halted, these organizations will be forced to reduce services or, in some cases, continue providing care without compensation.”
If you notice your patient is also receiving these affected services, let them know that they may have to make some decisions about alternative care.
Educate your staff.
Amy Lerman, a health regulatory lawyer with the Epstein Becker Green firm in Washington, D.C., says patients aren’t the only ones who need to know about these changes. Not only providers but also schedulers, billers and others need to understand “how the reversion back to pre-pandemic Medicare requirements for telehealth services will impact the operations of the practice, in terms of both clinical and administrative workflows,” she says. “Training on to handle patient questions, to adjust appointment scheduling, and to navigate the new billing landscape, can and should be part of these educational efforts.”
A flagship publication of DecisionHealth, Part B News helps physicians, compliance officers, and other healthcare experts make decisions on issues related to their business operations. The article was written by Roy Edroso and is available by subscription.
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