Executive Briefing for Commercial, Medicare, and Medicaid Payers
Foreword
Healthcare regulations accelerated significantly across federal and state levels in 2025, and they continue to expand into 2026 with direction already emerging for 2027. Key areas policymakers are targeting include the following:
| Area of Regulation | Federal Activity | State Activity | Payment Integrity Risk (Claim-Level Impact) |
| Prior Authorization | API mandates, performance reporting | Gold-card laws, mandated timelines | Accelerated approvals can lead to expedited reimbursement without coding accuracy. |
| Transparency | Hospital price transparency requirements | Gold-card laws, mandated timelines | Published rates don’t eliminate upcoding exposure and site-of-service overpayments. |
| AI in Utilization Management | Governance and oversight expectations | Disclosure and human review mandates | Reduced automation can create inconsistency in payment accuracy. |
| Provider Consolidation | Transaction oversight | Private equity and merger scrutiny laws | Increased pricing complexity can make it difficult to validate accuracy and detect outlier billing. |
While these policies may increase oversight and transparency, they are not eliminating payment accuracy risk. This report focuses specifically on regulatory actions that the CERIS team believes could have the greatest impact on payment integrity functions across all lines of business (Commercial, Medicare, Medicaid). It outlines where financial risk is increasing, and what operational gaps payers need to close to strengthen cost management.