Prepared for: Payer Executives / Claims and Payment Integrity Leaders
Executive Summary
Across 2025, payers confronted a perfect storm of rising medical costs, intensifying regulatory changes and oversight, unprecedented provider consolidation, and the rapid acceleration of AI-driven billing and advanced revenue-cycle tools. These forces have fundamentally shifted the expectations placed on PI programs and moved them into enterprise-level strategic opportunities focused on accuracy, transparency, and friction reduction. Payers with high PI results last year embraced a prevention-first mindset. They modernized their data and contract logic, integrated real-time editing, and built collaborative provider engagement models. All of this to help reduce abrasion while improving accuracy. At the same time, the rise of private equity backed provider groups, centralized billing and increasingly sophisticated coding optimization technologies challenged traditional PI teams in new ways.
As we enter 2026, PI is poised for even greater transformation. AI and real-time adjudication will continue to accelerate and grow increasingly sophisticated. Regulatory expectations will tighten, and the financial and operational consequences of inaccurate payments will grow more severe. The lines between PI, utilization management, risk adjustment, and value-based care will continue to blur, creating a new strategic imperative for payers to design and execute PI as a discipline across the enterprise.
Payers in 2026 will focus on elevating PI from a corrective function to a competitive advantage powered by prevention, transparency, real-time intelligence, and strong, independent partners who can help them navigate the next decade of healthcare PI changes.
This paper offers a forward-looking perspective on the forces reshaping the PI ecosystem, the lessons 2025 taught us, and the operational, technological, and strategic capabilities payers should consider building to stay ahead of rising complexity and cost. Sections include:
- Lessons Learned in 2025
- Outlook and Strategic Forecast for 2026
- A 2026 Payer Preparedness Checklist