Less Paperwork Up Front. More Scrutiny After Payment.

2027 Fee Schedule: Joint Replacement Work RVUs Cut About 17–21%

Published: Proposed rule Jul 16, 2026 (CMS-1848-P). Healio analysis Oct 8, 2026. MedPAC Payment Basics Oct 2026.

CMS proposed cutting work RVUs for total knee (27447) by 16.6%, total hip (27130) by 19.6%, total shoulder (23472) by 19.0% and shoulder hemiarthroplasty (23470) by 20.8%, deeper than the AMA RUC recommended.

Separately, MedPAC projects the 2027 conversion factor will fall 1.19% for qualifying advanced APM participants and 1.68% for everyone else.

The final rule is expected by Nov 1. The Centers for Advanced Orthopaedics (Oct 14) is urging Congress to pass the Patients First Act (H.R. 9693), which would tie Medicare physician updates to inflation.

Code-level percentages are as reported by Healio; we did not re-check them against the Federal Register tables. Combined-cut estimates of about 20% (AAHKS, TOA) are association estimates.

Takeaway: Model the hit now. You'll have about eight weeks between the final rule and Jan 1.

Bottom line for your practice/ASC: Pull your 2026 volume for the four codes, apply the proposed values and the lower conversion factor, and check any surgeon contracts paid per wRVU.

Proposed Rule Would Stop Paying for Vendor-Run Remote Monitoring

Published: Oct 12, 2026

TMA warns the proposed 2027 fee schedule would pay for remote patient monitoring only when clinical staff employed directly by the physician or practice provide it. Services contracted to third-party vendors would no longer qualify.

Takeaway: If a vendor runs your RPM/RTM program, the revenue may disappear Jan 1.

Bottom line for your practice/ASC: Find out who actually performs your monitoring work, and price out bringing it in-house before the final rule.

Cigna's New CareCore Portal Brings "Partial Denials"

Published: EviCore provider orientation, October 2026

Starting Oct 31, 2026, Cigna prior-auth requests handled by EviCore move from the MedSolutions portal to CareCore. Open requests submitted before Oct 31 can still be worked in MedSolutions, and older authorizations stay viewable there through Jan 31.

The new process can issue a "partial denial": the procedure is approved but the requested site of care is not.

Takeaway: An approval is no longer the whole answer. Read the site-of-care line.

Bottom line for your practice/ASC: Train schedulers to confirm the approved site before booking. Have clinical justification ready when a case needs the hospital.

Superior and Ambetter Add Site-of-Care Review for Shoulder, Hip, Knee and Spine

Published: Oct 5, 2026

Beginning Dec 5, 2026, Evolent will steer ordering providers to a preferred site of care during prior-auth intake for Superior HealthPlan Medicaid (STAR, STAR+PLUS, STAR Kids, STAR Health), CHIP, Marketplace and ICHRA members. Choosing a hospital for a case that can be done outpatient requires an allowable exception or clinical justification.

Takeaway: Good news for ASCs, more paperwork for hospital cases.

Bottom line for your practice/ASC: Review Evolent's Place of Service policy 1773 and build exception documentation (comorbidities, ASA class) into your intake.

Centene Launches a Nationwide Gold Card in November

Published: Oct 13, 2026

Centene will launch its National Performance-Based Gold Card Program in November 2026, initially for more than 160,000 qualifying providers. Eligibility rewards a track record of following evidence-based guidelines. The service list isn't public yet.

Takeaway: Your approval history is now an asset. Or a liability.

Bottom line for your practice/ASC: Watch for an invitation. Clean, complete submissions now build the record that qualifies you later.

CMS Gets Its Own Permissive Exclusion Authority

Published: Oct 14, 2026

HHS delegated its authority under Section 1128(b) of the Social Security Act, permissive exclusion, to the CMS Administrator. CMS says it is "uniquely positioned to investigate, identify, and develop the evidentiary basis" for exclusions.

Takeaway: The agency that pays your claims can now build the case to exclude you.

Bottom line for your practice/ASC: Close out open audit findings, keep ownership disclosures current, and treat CMS documentation requests as seriously as OIG ones.

BCBSTX: Medicaid Post-Payment Reviews and Inactive Record ID Cancellations

Published: Oct 1, 2026 (reviews). Oct 8, 2026 (Record IDs).

BCBSTX began post-payment reviews of Medicaid claims Oct 2, with a lookback to claims paid Jan 1, 2026 onward.

Separately, if no claim has been filed under a billing or rendering NPI and TIN with a date of service in the past 24 months, BCBSTX may cancel that Record ID, which can terminate the provider from associated networks.

Takeaway: One notice reaches backward into paid claims. The other reaches into your roster.

Bottom line for your practice/ASC: Pull Medicaid documentation for 2026 claims now, and check dormant TINs and part-time providers.

Aetna Adds Claim Edits Jan 1 and May Request Records for Implant Claims

Published: Aetna OfficeLink Updates, October 2026

Beginning Jan 1, 2027, Aetna's Claim and Code Review Program adds new claim edits for commercial, Medicare and Student Health members. Aetna may request medical records for high-dollar, implant, anesthesia and bundled-services claims.

In the same update, Aetna dropped commercial precertification for OrthoVisc (J7324), effective Oct 1, 2026.

Takeaway: Implant-heavy ASC claims are squarely in the review zone.

Bottom line for your practice/ASC: Check the new edits in Availity before January and make sure implant invoices and op notes travel with the claim.

Medicare Brace Prior Auth Expands Oct 28; Overpayment Interest Hits 11.875%

Published: CMS DMEPOS prior auth page (update dated Jul 29, 2026). CMS transmittal R14006FM (effective Oct 21, 2026).

Medicare prior auth becomes a condition of payment nationwide Oct 28 for four more orthosis codes, plus one support surface and one wheelchair base. Two upper-limb orthoses phase in, reaching Texas Jan 26, 2027. Probationary prior auth for newly enrolled DMEPOS suppliers began Oct 15.

Separately, the Medicare overpayment interest rate is 11.875% effective Oct 21, 2026.

Takeaway: If you dispense braces, check codes now. If you owe Medicare money, pay it.

Bottom line for your practice/ASC: Confirm which of your brace codes are on the Required Prior Authorization List. CMS's page doesn't list the codes by number, so check the Federal Register list.

• Humana revised its Medicare Advantage prior-auth list. It includes Zilretta and denosumab products. https://assets.humana.com/is/content/humana/2026%20Medicare%20Prior%20Authorization%20Listpdf
• BCBSTX expands its commercial Medical Drug Benefit Program Jan 1, 2027, with limits on some office-administered drugs when a self-administered version exists (Oct 14, 2026). https://www.bcbstx.com/provider/education/education/news/2026/10-14-2026-medical-drug-benefit-program
• Texas Medicaid is reviewing inpatient claims with dates of service Sep 26, 2024 to Aug 22, 2026 for the spell-of-illness limit, with recoupment from future payments (Oct 14, 2026). https://www.tmhp.com/news/2026-10-14-review-inpatient-claims-spell-illness-limitation
• KFF: HCSC (BCBSTX's parent) exits 498 counties in Medicare Advantage for 2027, and Centene exits 359 (Oct 9, 2026). Open enrollment runs Oct 15–Dec 7. https://www.kff.org/medicare/medicare-advantage-plan-availability-varies-widely-by-county-for-2027/
• CVS agreed to pay $315M to resolve DOJ opioid-dispensing allegations (Oct 13, 2026). Expect more pharmacist callbacks on post-op scripts. https://www.justice.gov/opa/pr/cvs-agrees-pay-315m-illegally-filling-unlawful-opioid-prescriptions-and-submitting-false