Medicare tests telehealth claims against the originating site rule that was in effect on the date of service, not the rule in effect when the claim is reviewed. That rule has been anything but stable. A lapse tied to the October 2025 government shutdown suspended the waiver, Congress restored it days later, and the current extension runs only through December 31, 2027. Providers who bill on the assumption that today's location flexibility is permanent are building a documentation gap that a Unified Program Integrity Contractor can exploit on retrospective review, after the claims are paid.
The Default Rule Congress Keeps Suspending
Absent a waiver, Section 1834(m) of the Social Security Act limits Medicare telehealth to patients located at a qualifying originating site: a physician or practitioner's office, a hospital, a critical access hospital, a rural health clinic, a federally qualified health center, a skilled nursing facility, a community mental health center, a renal dialysis facility, or a mobile stroke unit, generally located in a rural health professional shortage area or outside a metropolitan statistical area. A patient's home has never qualified as a default originating site, except for end-stage renal disease home dialysis, substance use disorder treatment, and mental health services. That baseline is the rule scheduled to resume on January 1, 2028, for every service except behavioral health.
The Waiver Currently in Effect
Under the waiver Congress has extended in stages since the COVID-19 public health emergency, the geographic and site-type restrictions are suspended for all Medicare telehealth services through December 31, 2027. CMS confirms beneficiaries may receive telehealth services anywhere in the United States and its territories, including the home, regardless of rural or urban status. Behavioral health telehealth is different in kind: the Consolidated Appropriations Act, 2021 permanently removed the geographic and site restrictions for behavioral health, so that carve-out survives the January 2028 sunset even if the general waiver is not extended again. The October 2025 lapse briefly reinstated the default rule; CMS resolved it by paying claims from that period as if the lapse had not occurred, though providers billed for weeks without clarity on which rule applied.
Why a Temporary Waiver Creates Audit Exposure
Program integrity contractors do not audit against the rule in effect today. They audit against the rule that governed each claim's date of service, so a claims history spanning a lapse, a retroactive fix, and a multi-year extension can contain several different compliance standards inside one lookback period. A UPIC or Medicare Administrative Contractor reviewing a telehealth claims universe can flag place-of-service coding that does not match the beneficiary's actual location, treat an unsupported home-originating claim as an overpayment, and apply extrapolation across the sample if the pattern repeats. Billing under an assumption that the waiver would keep being extended does not excuse an inaccurate claim; a repeated pattern can turn an administrative recoupment into False Claims Act exposure. Telehealth Fraud Enforcement: What DOJ Actions Target covers the enforcement patterns that turn a documentation gap into a referral.
Program integrity contractors audit telehealth claims against the originating site rule in effect on the date of service, not the rule in effect when the audit begins.
What Telehealth Providers Should Document Now
Two habits close most of the gap. First, document the beneficiary's physical location for every telehealth encounter, not just the flexibility that permitted it, since that record is what a retrospective review will test. Second, confirm the POS 02 or POS 10 code matches where the patient actually was, since CMS pays home-originated telehealth at the non-facility rate and a mismatched code invites its own review independent of the site question. Providers billing across state lines should also track how originating-site flexibility interacts with licensure requirements; Practicing Across State Lines: Telehealth Licensure Enforcement addresses that overlap directly. This documentation is not optional insurance; it is the record a program integrity review will test years after today's expiration date has already changed again.
Why Early Legal Counsel Is Critical
It is critical that providers promptly retain experienced healthcare defense counsel upon receiving a telehealth claims audit notice, an additional documentation request, or any related government inquiry. Early legal intervention can protect the provider's rights, shape the documentation record before a sampling methodology hardens into an extrapolated demand, avoid inadvertent admissions in responses to the contractor, and allow counsel to communicate with the contractor on the provider's behalf. Delaying representation can lengthen the review, increase the eventual professional fees, and expose the provider to unnecessary risk.
How Health Law Alliance Can Help
Health Law Alliance has handled 5,000+ matters across healthcare regulatory and audit defense over 25+ years, including telehealth originating-site disputes and the claims audits that follow shifting CMS guidance. If your practice bills Medicare telehealth services or has received a claims review tied to originating-site documentation, contact Health Law Alliance's telehealth defense attorneys for a free, confidential consultation.
