On Oct. 1, CMS announced a temporary payment hold for certain claims. After a series of vague and confusing updates from the agency, an Oct. 21 announcement put an end to the temporary payment hold for most services and provided helpful clarifications.
With its Oct. 21 update, CMS provided clarification that it would end the temporary claim payment hold and start paying claims impacted by the expired extenders policies at the lower rates. However, CMS said it will continue to hold payments for claims impacted by the temporarily expired telehealth coverage flexibilities.
This means that practices in areas with a work Geographic Practice Cost Indices (GPCI) factor less than 1.0 will have lower Medicare reimbursements for these claims unless and until Congress extends the 1.0 floor (hopefully they will be retroactive to Oct. 1). It also means that allergists will not get paid for many Medicare telehealth services until those policies are similarly extended.
Additionally, TRICARE posted an update on its website that it may not be able to process or pay medical claims received on or after October 1, 2025, until funding is resolved.
Background
CMS originally announced the temporary claims hold because several legislative Medicare coverage policies expired on Oct.1. These temporary coverage policies are colloquially referred to as Medicare “extenders” because Congress extends them every year on a bipartisan basis. Congress was expected to extend them again as part of a government funding bill that had to pass by the same Sept. 30 deadline (which did not happen). Congress also did not pass separate legislation on the extenders policies even though nothing is preventing them from doing so.
The extenders’ policies that directly impact allergists include:
- The temporary Medicare telehealth coverage flexibilities first passed during the COVID-19 pandemic that removed the geographic limitation on telehealth services and the distant site/originating site requirement, among other things.
- Establishing a 1.0 floor for the work (GPCI), which benefits many rural areas that have a work GPCI adjustment below 1.0.
Confusion over CMS updates on claims payment hold
As Medicare typically does not pay claims for at least 14 days, CMS was waiting to see if Congress would address the extenders policies before it had to start paying claims with a date of service on or after Oct. 1. Holding payments would allow CMS to avoid reprocessing claims after Congress extends these policies (likely retroactive to Oct. 1).
After these 14 days passed, CMS issued an update saying it would temporarily hold payment for all claims paid under the Medicare Physician Fee Schedule (PFS). Later that day, CMS walked that back, saying the claim payment hold would only apply to “select” claims impacted by the expired extenders.
Additional information on GPCI floor
There is a lot of confusion about which areas are impacted by the expired GPCI floor. The expired GPCI floor policy only applies to the Physician Work (PW) Relative Value Unit (RVU) GPCI adjustment. The work RVU is one of three components of a service’s reimbursement.
The lower GPCI floor’s impact on total reimbursement is different for each geographic area. To get a better understanding of how it impacts your practice, using this table, apply the “2025 PW GPCI (without 1.0 Floor)” for your geographic area to the Work RVUs from this table of codes commonly billed by allergy practices.
Outlook for a resolution
After Congress eventually extends the policies (as is expected), CMS will issue guidance on how it will address the claims impacted during the period when the policies were temporarily expired. During similar situations in the past, CMS automatically reprocessed claims without requiring providers to resubmit claims. However, CMS must make an official announcement before anything is certain.
The extenders policies will continue to be linked to the government shutdown for now, as federal funding legislation is the most likely legislative vehicle for extending the Medicare coverage policies. If the shutdown continues for an extended period of time, Congress could choose to address the extenders policies separately.
The College’s Advocacy Council will continue to monitor and update you on this issue and how it affects your practice.
THE ADVOCACY COUNCIL – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
