Key takeaways from this episode

• A government shutdown will not stop Medicare or Medicaid from processing and paying claims. Both are mandatory programs funded outside the annual budget bill, and the MACs are private contractors, not federal employees; a slowdown is possible only if a shutdown runs beyond about 20 days, and even that risk is considered small.
• Telehealth coverage for traditional Medicare patients at home ends September 30 under the current rules. It has been funded through continuing resolutions since the public health emergency expired, and the failed stopgap would have extended it, along with the budget, to November 21.
• For traditional Medicare telehealth patients, choose one of four paths: reschedule to in-person, push visits out a few days at a time, have the patient pay for the non-covered visit, or gamble on retroactive reinstatement to October 1. Weigh the staff lift and how much of your practice depends on telehealth.
• Get an ABN signed before providing a telehealth visit to a traditional Medicare patient. It puts the patient on notice, avoids a surprise bill, and protects you from a takeback if Medicare later pays retroactively; it can be signed remotely with DocuSign or a similar tool.
• Medicare Advantage plans may keep covering telehealth, so check each plan's bulletins and your contracts. Larger MA plans will probably continue coverage; smaller ones may not, and commercial plans are unlikely to change.
• Do not count on Congress making telehealth coverage retroactive. The 2024 conversion factor update was not made retroactive and the 2025 conversion factor was not touched, so recent Congresses have been less willing to pay retroactively than in the past.
• Otherwise, keep operating as usual, and consider a line of credit or cash reserve if the shutdown drags on. Continue eligibility checks, prior authorizations and commercial and Medicaid billing unchanged; non-telehealth services will be paid, so the only question is timing.
• Watch for the 2026 Medicare final rule to be delayed by furloughed CMS staff. CMS has already had staffing cuts and another 50% of the workforce could be furloughed or fired during a shutdown, which could push the final rule out until just before the December seminar.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 260, recorded September 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Where the shutdown stands and what is holding up the continuing resolution

[00:00] Scott Painter: On this episode: the potential government shutdown and the impact on telehealth. Stay tuned. Welcome to episode 260 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. Let's get into it. We want to talk today about the impossible, and it looks like a little more probable, government shutdown. As we record this, the date is September 26th, so this is what we know right now. I know there's a lot of information out there. This is the latest that we have. All right, Mark, give us the good, the bad and the ugly.

[01:00] Mark Painter: The bad, overall, is it does not look like Congress is going to come to agreement before the government shuts down. There was a scheduled meeting between Trump and the Democrats to work out a compromise that was canceled. The House is on recess as a move to try and pressure the current stopgap measure that was passed narrowly in the House and then failed in the Senate. As you probably know, we need 60 votes in the Senate to pass a budget resolution, so there is going to be a need for some bipartisan support in the Senate to get any stopgap measure put in place.

Now, that stopgap measure did extend the budget through a continuing resolution until November 21st, and that did include the extension of telehealth through November 21st. The idea was that if they passed a bill that had nothing in it that people disagreed about, they would then be able to sit down in the meantime and figure out a year-long budget by the 21st. What was not included, the pill that stopped everything, or where the Democrats are focusing, is the extension of credits to help keep healthcare exchange premiums from doubling for some people. They're really trying to make sure that funding is extended as part of any continuing resolution, and at this point they're saying they're not going to budge. The Republicans are not going to budge either, even though it's a temporary bill to push things forward. So both sides are seemingly entrenched, and our looming shutdown is Monday. At this point, it's hard to see avoiding a shutdown, at least for some time.

I looked back at some of the history of shutdowns. The longest in history was 35 days. The next longest was 21 days, and most of the others ranged from 10 to 15 days. The administration has said that with a shutdown, they are going to determine whether or not they can actually remove or fire some of their employees instead of just furloughing them. We're not sure whether that's a negotiating tactic or a real concern. As we've all seen, a lot of our folks in the federal government, specifically for us at CMS, have already had their staff cut, and if the government is shut down, another 50% of the workforce will be furloughed or fired. So we'll have to keep an eye on that. That does put a wrench in a lot of things.

Medicare and Medicaid will keep paying claims during a shutdown

Now, Medicare and Medicaid funding, for the most part, is not part of the yearly budget bill. Those are mandatory programs with funding established elsewhere, and that's why the Medicaid discussion we had surrounding the big bill back in July for the tax relief included all of that discussion around Medicaid and those cuts, which are coming next year. So the general belief, and what we know, is that the funding for Medicare is there for the majority of Medicare. We also know that the MACs are not federal employees. The MACs are private companies, so in the past, payments for claims and claim processing have continued, based on that permanent funding and on who's actually processing the claims. We fully expect that's going to continue. The government shutdown is not going to stop Medicare from processing and paying claims.

What is at risk in a longer-term shutdown is the ability of the actual CMS folks to continue to provide everything that supports Medicare and the MACs. I don't think that's necessarily going to stop claims processing, but there could be a slowdown depending on how long the shutdown lasts. That is one concern we have out there: if the shutdown lasts for a long time, will that affect how CMS supports the MACs, and the timing of the revenue to the MACs, and will they slow down in their payment structure because of that function behind the scenes? We don't expect that to be an issue if the shutdown is in that 15-to-20-day range. If it goes beyond 20 days, that's where something could happen with slowdowns. Now, that's basing things on the past and on the way the system is designed to work, so I feel pretty confident those things will go forward. We won't see disruptions in Social Security, those types of things on the mandatory program side.

I will say this administration has been a bit unpredictable. Is there a risk that the past is not followed and tradition is not respected? Yes, but I think it is a fairly low risk, because suspending healthcare for 68 million Americans and stopping that process is not politically savvy for any party. And the only payer larger than Medicare in the United States is Medicaid, which of course is administered by the states. So everything we have points to the fact that you'll continue to be paid by Medicare and Medicaid even during a government shutdown. I don't want to run the alarm flag up. Is there a small potential out there? I'm going to say yes, but very, very small. I know there's been some information circulated that Medicare does stop processing, but I can tell you from multiple sources I've read, nobody expects that to happen.

Scott: Ray, do you have any comments or questions?

[08:00] Dr. Ray Painter: I think this is a situation none of us would like to see, with our partisan approach to life at the head of the government. It might be unpredictable, but it's hard to believe, with everything that goes on, that they'd let this ride for very long. There has to be a group in there somewhere with a compromise.

What changes for the practice: telehealth for traditional Medicare stops September 30

Scott: So true. Mark, can you walk us through what you would do for each of the different areas? Given that there is a government shutdown, what should the urologist do? The APPs, anything different, or are there other behaviors they need to look at? And what about the front office and scheduling? What would you recommend?

[09:00] Mark: Generally, I wouldn't recommend changing anything. You still need to check your Medicare patients to see if they're on Medicare Advantage. You need to get your prior authorizations. You're going to deal with commercial insurers the same way, and you're going to deal with Medicaid the same way. So I don't see any major changes for the most part.

Now, telehealth for traditional Medicare is caught up in the budget. The way it's been paid for and covered since the expiration of the public health emergency has been through a continuing resolution as part of the budget. Unfortunately, on September 30th, telehealth coverage under the current rules does stop. So you are going to need to do something for your patients who are receiving telehealth at home. That will no longer be covered by traditional Medicare. Medicare Advantage plans can continue to cover that, so you're going to want to check with your Medicare Advantage plans to see if those telehealth services are going to be continued. I think most will continue to cover them. Maybe your smaller ones won't, but your larger ones probably will, given the way the rules and regulations were set up. But it's possible they would suspend it, so I would take a look at what you're doing with your Medicare Advantage plans to see if you want to keep providing those services to those patients.

For your traditional Medicare patients, those people no longer have the ability to have telehealth provided to them from their home. So you will need to either reschedule those patients to in-person visits, or push the visits back as an alternative, gambling that this shutdown is only going to last 15 to 20 days and that we're pretty certain telehealth will be part of a continuation moving forward, given that nobody's balked at that particular issue. You could just push them out a few days and hope this gets resolved, and then push them again if it doesn't. That's a bit of a lift, but that's an option. The other option would be to let the patients know that they can pay for a telehealth visit, because it is non-covered in the home. And the last option would be the potential of having that coverage reinstated retroactively to October 1st. You could gamble that Medicare will come back and pay for those somewhere down the road, the head-in-the-sand approach.

I think those are all options available to you, and really it's going to depend, for each practice, on, one, what kind of a lift that's going to entail for your staff and for your physicians and APPs, and two, how much of your practice is based in telehealth. All those things need to be taken into account. And remember that this is Medicare only that we really know is going to expire on October 1st, unless your Medicare Advantage plans have specifically notified you they're not going to cover it if Medicare doesn't, or your commercial plans do the same. I doubt the commercial plans will shift. The Medicare Advantage plans would be the one place I would focus my efforts on finding out what they're going to do: looking at their bulletins, talking to them, and looking at your contracts to see how closely they follow Medicare guidelines.

Will Congress make telehealth coverage retroactive?

[13:00] Scott: And historically, how often do they do a retroactive payment? We've seen it a few times, but is it more often than not in this situation, would you say? Or is it just hard to predict?

[14:00] Mark: It is hard to predict, but I would say, looking at the last couple of continuing resolutions we've seen, at the beginning of this year and the beginning of last year, telehealth wasn't caught up in those because they extended telehealth somewhat separately. But Congress in 2024 gave us a conversion factor update that was positive, and they did not make that retroactive. In the past they had made it retroactive and made those adjustments, but in '24 they didn't, and in '25 they didn't actually touch the conversion factor. So that doesn't give us a window into the retroactive side, but it did give us a window into the fact that budget balancing is a consideration for the federal government, and that may come into play depending on how long this lasts. Telehealth is a small piece of the budget, so they could make it retroactive, but they certainly don't have to. And we've seen that they're not as willing to go retroactive recently as they have been in the past.

Scott: All right, Ray, any comments?

[15:00] Ray: Mark, it sounds like you're saying that even though the government shuts down, we really ought to continue our practice as usual and take care of the patients, and chances are we will get paid. And even on telehealth, if you have somebody who really needs it, there is a chance you might get paid retroactively. So it's not as big a deal for us as it is for most of the economy.

[16:00] Mark: I'm going to agree with you partially. I don't think you should disrupt your practice for your standard services. Your Medicare and Medicaid payments, I think, are going to keep coming in. Ultimately you might want to look at a little bit of a line of credit or a war chest if this extends, but those services you provide that are not telehealth will be paid for eventually. It's a question of timing, not a question of whether or not you're going to get paid. So for that, I would say absolutely, keep going.

The telehealth issue is a little bit different. I agree with you, of course, that the patient comes first, and if you are in a position that you can accept a few services that are not covered for telehealth and gamble that they will make that retroactive, you could. But at this point in time I might actually consider charging the patient, mainly to drive them to put pressure on Congress to pay for telehealth, because it's a needed service. And yes, the shutdown is going to impact other industries much more than anything else. The travel industry, national parks shutting down, there are a lot of things that will be impacted. Medicare and Medicaid are lower risk on the entire side. Telehealth is a little bit higher.

Using an ABN to put telehealth patients on alert

[17:00] Ray: You reminded me of one thing, sort of in between. What do you think about getting an ABN, since you don't know whether it's going to be covered or not? That would put the patient on alert and tell them to go talk to their congressman, but it wouldn't put you in the position of having to pay that money back if Medicare eventually paid you.

Mark: I would agree with that. I think an ABN is a good idea. You can do that remotely with DocuSign or in a number of different ways. Putting that patient on alert is key. A surprise bill is a surprise bill, and nobody likes that. So letting them know that you're going to charge, yes, and getting an ABN as an extra cushion, that's a good idea.

Sponsor, seminar reminder and final thoughts

[18:00] Scott: All right, let's wind this episode up. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prs for specials for our listening audience. Also, I want to remind you that the Urology Advanced Coding and Reimbursement Seminar is coming up in Las Vegas in December and New Orleans at the end of January. We are finalizing our agenda in the next few weeks, and on the agenda is going to be AI. It is a very big topic, and it's going to have a big impact on your practice moving forward on the administrative side: coding, reimbursement and documentation. We are going to be covering that in our seminar, and we would like to have you as part of the discussion. You can go to prsnetwork.com, and on the homepage there's a seminar registration button, or you can go to the episode page at prsnetwork.com/260 for episode 260, where there are links as well. Okay, let's get some final thoughts. Mark, what are your final thoughts?

[19:00] Mark: I think I've given you my thoughts pretty deeply on the shutdown and your immediate actions. The other thing I will add is something we are going to watch as the government shutdown progresses: the loss of federal employees may affect when our final rule comes out. That's another domino we're going to keep an eye on. If it extends long enough, we may actually be scrambling to read the Federal Register right before the Urology Coding and Reimbursement Seminar. So there's a lot to keep an eye on here. The federal government has a big hand in healthcare, without a doubt, and that's going to be part of our discussions at the seminar.

We also have in the mix everything that's been going on with new technology, all the new releases and new exciting ways to treat our patients, which is another thing we're going to address at the seminar. That should not be affected by the shutdown, but may be affected as we look at what happens in the rules for next year. This is a domino that starts to drop. It's not a small thing to have the government shut down, and that's one of the reasons we bring it to you and go through it. The other side, though, is that even with all of this craziness swirling around us, from AI to the federal government, we still have to provide the service to the patients. Ultimately, what we're trying to help you do is keep your financial health up so that your clinic can continue to focus on patient care.

[21:00] Scott: Ray, final thoughts?

Ray: It's a pain, but not a deal breaker. Life will go on and your practice will survive.

Scott: Very good. That's all we have for today's episode. Thank you all for listening. Take us out, Ray.

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