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There has been more medical documentation showing what your claims are.
Executive summary
Recent reporting and agency notices show rising medical payments per claim in workers’ compensation and operational turbulence in Medicare claims processing after policy changes on October 1, 2025. The Workers’ Compensation Research Institute (via Insurance Journal) finds medical payments per claim increased — e.g., Pennsylvania rose 14% in 2023 — driven by utilization, price and fee-schedule updates [1]. At the same time CMS guidance and industry newsletters document temporary holds, selective returns, and staggered releases of certain Medicare telehealth and other claims tied to expiring pandemic-era flexibilities and administrative decisions [2] [3] [4].
1. Workers’ compensation: medical costs per claim are climbing again
A WCRI-based analysis summarized by Insurance Journal reports that after a post‑pandemic plateau, medical payments per workers’ compensation claim “recently started increasing,” with states showing divergent experiences — Pennsylvania’s per‑claim payments rose 14% in 2023 and Delaware saw roughly 7% annual growth from 2021–2023 — and the report attributes the rise to higher utilization, price increases, and state fee schedule updates [1]. This frames a clear narrative: cost drivers are a mix of volume (more services), unit price (higher reimbursements or charges), and policy levers (fee schedule adjustments), not a single cause [1].
2. Medicare telehealth claims: holds, selective payments, and returns
CMS communications and industry groups show Medicare processing was uneven after October 1, 2025: CMS instructed MACs to temporarily hold many claims affected by expired legislative provisions while processing or releasing telehealth claims it could confidently identify as payable (notably behavioral and mental health services) and later directed that certain held telehealth claims submitted through November 10, 2025 be returned to providers for refiling or correction [2] [3] [4]. The American Medical Association flagged ongoing uncertainty about whether MACs returned all held claims and urged further CMS clarification [5].
3. Why some claims were held: statutory limits, coding complexity, and operational strain
CMS has said many statutory telehealth payment flexibilities that had been extended during the COVID emergency reverted on October 1, 2025, creating categories of claims MACs could not automatically pay without more information; CMS therefore held claims until it could confirm eligibility under Section 1834(m) or related rules [4] [2]. Providers and billing experts also point to routine coding and billing complexity — frequent CPT/HCPCS/ICD updates and NCCI edits — as a practical reason claims get rebilled or denied, increasing administrative churn [6] [7].
4. What “returning claims to providers” means in practice
CMS’s MLN Connects notice explains that for a defined subset of telehealth claims (submitted by Nov. 10 with dates of service on/after Oct. 1, 2025), the agency will return those claims to providers so they can resubmit or otherwise resolve the issue — a step framed as improving cash flow and operational clarity for practitioners [2]. Independent writers and trade outlets interpret returns variously: some view it as a pragmatic fix to process what CMS can identify as payable now, others see it as shifting administrative burden back to providers [8] [2].
5. Competing viewpoints and consequences for providers and payers
Clinician groups (e.g., AMA) press CMS for clearer, consistent handling and prompt payment, noting that ambiguous MAC actions create cash‑flow problems and care‑delivery headaches; CMS counters that selective holds are necessary to ensure payments conform to current law and to avoid improper payments [5] [3] [2]. Insurers, state regulators, and researchers emphasize that fee schedule updates and coding edits can materially change per‑claim costs and downstream payments [1] [6].
6. Limitations of current reporting and unanswered questions
Available sources describe the mechanics of holds, selective releases, and fee‑schedule impacts, but they do not, in this set of reporting, provide comprehensive national totals for returned or delayed Medicare claims nor exhaustive data tying the workers’ compensation increases to specific billing or clinical categories [1] [2]. Sources do not mention detailed provider‑level financial impacts or longitudinal national improper‑payment estimates tied exclusively to the October 1 changes — those figures are not found in current reporting [1] [2].
7. Practical takeaways for clinicians, billers, and policymakers
Providers should audit telehealth submissions from Oct. 1 onward for appropriate place‑of‑service and diagnosis coding, watch MAC communications for reprocessing windows, and be prepared to resubmit returned claims; revenue‑cycle teams should prioritize claims flagged by CMS lists of HCPCS codes and monitor NCCI edits and CPT/HCPCS updates to reduce rebill cycles [2] [6] [7]. Policymakers must weigh the tradeoff CMS cites — preventing improper payments — against the administrative cost and care disruption documented by physician groups [2] [5].
If you want, I can extract the specific HCPCS/code lists CMS cited for the telehealth returns and map them to common clinical services so you can see which billing lines are most likely affected (sources above reference those lists but would need to be opened for code‑level detail) [2].