Less Paperwork, More Policing

OPINION. This is a point-of-view piece, not news reporting. It relies only on facts reported, sourced and dated in that week's issue.

For two years, prior authorization has been the industry's favorite villain, and payers have noticed. This fall they're competing to announce relief. Our read for independent Texas Orthopedic practices and ASCs: the burden isn't shrinking. It's moving, from before the procedure to after payment.

Start with the relief, because it's real. UnitedHealthcare began eliminating 30% of its prior-authorization requirements on Oct 1 (UHC, Sep 1). Centene says it will launch a national gold card program in November for more than 160,000 qualifying providers (Centene, Oct 13). Aetna dropped commercial precertification for OrthoVisc on Oct 1 (Aetna OfficeLink, Oct 2026). Fewer forms, fewer phone calls. Take it.

Now look at what's arriving at the same time.

Site-of-care steering. Starting Oct 31, Cigna's EviCore requests move to a new portal that can issue a "partial denial": the procedure approved, the site of care denied (EviCore, Oct 2026). On Dec 5, Superior and Ambetter will steer shoulder, hip, knee and spine requests to a preferred site and require exceptions or clinical justification to pick a hospital (Ambetter, Oct 5). For ASCs that's partly good news. But "approved" now comes with an asterisk.

Post-payment audits. BCBSTX began reviewing paid Medicaid claims on Oct 2, looking back to claims paid since Jan 1, 2026 (BCBSTX, Oct 1). Texas Medicaid is reviewing nearly two years of inpatient claims and will recoup from future payments (TMHP, Oct 14). Aetna adds claim edits Jan 1 and may request records on implant, anesthesia and high-dollar claims, which describes a typical Orthopedic ASC day (Aetna OfficeLink, Oct 2026).

Roster housekeeping with teeth. BCBSTX may cancel any Record ID with no claim under its NPI and TIN in 24 months, which can end that provider's network participation (BCBSTX, Oct 8).

Enforcement. On Oct 14, HHS delegated permissive exclusion authority under Section 1128(b) to CMS itself (Federal Register, Oct 14). And if you're slow to repay Medicare, interest runs at 11.875% from Oct 21 (CMS, R14006FM).

And the pay cut. CMS proposed cutting work RVUs for total knee, hip and shoulder replacement by roughly 17% to 21% (Healio, Oct 8), and MedPAC projects the 2027 conversion factor will fall 1.19% to 1.68% (MedPAC, Oct 2026). The final rule is due by Nov 1.

Put it together. Front-end prior auth was visible: it delayed surgery, annoyed patients, and generated headlines. Back-end scrutiny is quieter. It shows up months later as a records request, an offset on a remittance, or a network letter. The total work may not shrink at all. It just lands on your billing office instead of your scheduler, and it lands after you've spent the money.

None of this makes the relief fake, and some of the scrutiny is fair; nobody defends sloppy billing. But practices that plan for "less paperwork" will be caught flat. Plan for different paperwork.

Four steps worth taking this quarter:

• Audit-proof your documentation. Assume every implant, anesthesia and high-dollar claim will be pulled. Op notes, implant logs and medical-necessity support should be complete when the claim goes out, not when the letter comes.
• Clean up dormant records. Pull every BCBSTX Record ID, NPI and TIN combination. Retire what you don't need and protect what you do: part-time surgeons, satellite locations, old TINs.
• Build site-of-care justifications now. Turn ASA class, comorbidities and inpatient criteria into a standard template so hospital-based cases aren't rebuilt from scratch each time.
• Push Congress. The Patients First Act (H.R. 9693) would tie Medicare physician updates to inflation (CAO, Oct 14). Call your representative before the final rule, not after.

Our take: enjoy the shorter prior-auth list. Then staff up for everything that comes after payment.

This is an opinion piece. The facts it relies on are sourced and dated in this week's issue. Disagree? Email [email protected].