Weekly roundup
Here’s what you missed last week!
🏛️ Policy & Payers
Update cheat sheets and templates now as CMS changed 2025 E/M billing guidelines.
Recheck telehealth workflows because Medicare’s temporary telehealth coverage extensions ended Oct 1.
Expect more chart scrutiny as Cigna’s downcoding policy targets higher-level codes with carve-outs.
Prep for extra hurdles if you’re in pilot states as CMS adds a prior authorization pilot.
Plan for patient churn and bad debt if enhanced ACA tax credits lapse; KFF projects premiums could more than double.
📈 Business & Tech
Watch payer partners leading on automation as three national insurers rank high for AI adoption.
Pressure PBMs for clarity as RxBenefits touts a transparent PBM model for self-funded employers.
NP/PA roles in derm have doubled and will keep rising, per a workforce review.
Tighten governance for APP teams as collaboration and scope vary by state in this operational guide.
Treat operations as a growth lever as physicians are urged to engage in practice management, not just clinical work.
⭐ Just for Fun
The Deep Dive
Medicare Telehealth Just Ended. Now What?
Why is it important? On October 1, 2025, Medicare's pandemic-era telehealth flexibilities expired. Although this could change with a possible extension, these changes have critical impacts that practices should be prepared for. For dermatology practices that built telehealth into their patient flow, especially for follow-ups, post-procedure checks, and rash consultations, this means immediate billing changes or claim denials.
So what does this mean, exactly?
Your Medicare patients can't do home video visits anymore. With rare exceptions, Medicare telehealth is now limited to rural areas and clinical originating sites. That means your suburban and urban Medicare patients need to come into the office for most dermatology visits.
The three big exceptions (none likely apply to most derm visits):
Substance use disorder treatment
Mental/behavioral health services
Home dialysis for ESRD patients
Your typical acne follow-up, mole check, or post-Mohs visit with a Medicare patient? Not covered at home via telehealth anymore.
Phone consultations are essentially dead for billing. Audio-only coverage narrowed dramatically. The old telephone E/M codes (99441–99443) were deleted. You can still have phone conversations with patients, but Medicare won't pay for them except in very limited mental health scenarios.
The window to use standard E/M codes (99202–99204, 99212–99214) with POS 02 or 10 for broad telehealth services officially closed on September 30, 2025. Furthermore, be advised that Medicare has explicitly stated it will NOT reimburse the new AMA dedicated telehealth codes (98000–98015). Practices must now adhere strictly to the pre-pandemic telehealth coverage rules.
One new code Medicare does pay: Code 98016 covers brief 5–10 minute virtual check-ins, but only for patients in Health Professional Shortage Areas (HPSAs). This could work for quick "does this look infected?" photo reviews or medication adjustment questions—but verify the patient's location qualifies using the HRSA tool first.
So what does this mean for practice workflows?
Medicare patients: You'll need to convert most telehealth appointments to in-person visits. Consider flagging Medicare patients in your scheduling system to default to in-office appointments.
Commercial payers: This is all over the map. Some insurers adopted the new 98000-series codes. Others reject them entirely. You'll need payer-specific coding workflows... what works for Aetna won't work for Medicare.
Good news on state laws: As of 2025, 24 states have telehealth payment parity laws requiring private insurers to reimburse telehealth at the same rates as in-person services. Check your state's rules at the Center for Connected Health Policy to leverage this with commercial negotiations.
Medicaid patients: Often broader coverage than Medicare, but varies by state. Verify your state's Medicaid telehealth policies.
ACO Exception: If your practice participates in a risk-based Medicare Shared Savings Program ACO with prospective assignment (ENHANCED track or BASIC track levels C, D, or E), you can continue providing telehealth services to prospectively assigned beneficiaries without geographic restrictions, including from their homes. This flexibility has been available since January 1, 2020, and remains in effect.
Please note, you must be licensed in your patient's state. Both you and the patient must be physically located in the U.S. (including territories) during the telehealth visit. If you've been seeing snowbirds in Florida via telehealth from your California practice, you need a Florida license. Until December 31, 2025, you can list your practice address on Medicare enrollment even if providing telehealth from home.
Your Action Plan This Week
Audit your schedule: Identify upcoming Medicare telehealth appointments and convert them to in-person or reschedule as non-billable courtesy calls (unless you're in an eligible ACO).
Update your EHR: Remove deleted codes (99441-99443), add payer-specific coding rules, and flag Medicare patients for in-office default.
Train your front desk: Schedulers need to know Medicare rules changed on October 1, 2025. They should verify insurance before offering telehealth.
Check HPSA eligibility: If offering code 98016 virtual check-ins, use the HRSA tool to verify patient locations qualify.
Review your commercial payer contracts: Negotiate telehealth rates and clarify which codes each payer accepts for 2025.
Consider your telehealth mix: For practices heavily dependent on Medicare, telehealth volume will likely drop. Plan accordingly for scheduling and revenue.
Bottom line: The golden age of Medicare telehealth dermatology is over. Rural practices and those in eligible ACOs retain some flexibility, but most urban and suburban practices need to pivot hard back to in-person visits for Medicare patients. Commercial payers remain variable, requiring careful payer-by-payer management. The practices that thrive will be those that audit quickly, update systems immediately, and communicate changes to patients proactively. Telehealth isn't dead for dermatology, but getting paid for it just got a lot more complicated.
FAQs
Q: Can we just offer telehealth as cash-pay instead of dealing with insurance?
A: Yes, but only if patients voluntarily choose to pay out-of-pocket. You cannot unilaterally decide to stop billing insurance for telehealth services. For Medicare patients, you must provide an Advance Beneficiary Notice (ABN) before collecting payment for non-covered telehealth services. The ABN informs the patient that Medicare won't pay and estimates their out-of-pocket cost. Without a proper ABN, you risk compliance issues and patient complaints.
Q: Our practice is near the state line. What if my patient is in Indiana but I'm in Kentucky?
A: You must be licensed in both states—the state where you're physically located during the visit AND the state where your patient is located. This applies even if your office is just minutes from the state border. Multi-state compacts can help streamline the licensing process, but there's no exception for proximity. Verify licensure before scheduling cross-state telehealth visits.
Q: What if my patient travels or has multiple residences (snowbirds)?
A: The patient's location at the time of the telehealth visit determines which state's laws apply. If your snowbird patient is in Florida when you provide the service, you need a Florida license—even if their primary address is in your state. Always confirm the patient's physical location before starting a telehealth visit and document it in their chart.
Q: Can I still bill Medicare for telehealth after September 30, 2025?
A: Only in very limited circumstances: if you're in a risk-based ACO with prospective assignment, if the patient is in a Health Professional Shortage Area (for code 98016 only), or for the narrow exceptions (mental health, substance use disorder, dialysis). For most dermatology practices, Medicare telehealth ended on September 30, 2025.
Q: Do I need the patient's consent to switch from telehealth to in-person?
A: Yes, always inform patients about appointment format changes. For established patients who prefer telehealth, explain why Medicare no longer covers it and offer options: reschedule as in-person, pay cash with an ABN (if applicable). Document these conversations.
Q: What about controlled substance prescribing via telehealth?
A: DEA rules under the Ryan Haight Act continue to evolve. Currently, prescribing controlled substances via telehealth requires either a prior in-person visit or qualification under specific exceptions. For dermatology, this primarily affects practices prescribing Schedule III-V medications like certain acne treatments. Stay current on DEA guidance as rules may change.
Q: How do I know which commercial payers accept the new 98000-series codes?
A: Contact each payer directly or check their provider bulletins. There's no standardized approach—some payers adopted the new codes, others still require traditional E/M codes with modifiers, and some have different requirements entirely. Create a payer-specific coding reference sheet for your billing staff to avoid denials.
Q: What happens if I accidentally bill a non-covered Medicare telehealth visit?
A: The claim will be denied. If you've already collected payment from the patient without a proper ABN, you may need to refund them. If this becomes a pattern, it could trigger an audit. Review your schedule immediately and proactively convert ineligible appointments to in-person visits.
Learn more:
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That’s it for this week.
This one was super fun. Hope you enjoyed it too.
