Payers focus on regulatory compliance ahead of 2026

Changing regulatory landscape creates payer pressure

Although payers still ranked rising healthcare costs as their biggest concern for the new year, policy changes have created a sense of urgency for health plan leaders.

Notably, 85% of payer executives said regulatory pressures are moderately or significantly impacting their costs and margins. This comes in the wake of Trump's tax law, passed in July 2025.

For example, the tax law has increased scrutiny of enrollment numbers and eligibility controls, the report authors said. Health plans need the right data in place to navigate new eligibility requirements.

To manage this, a quarter plan to tighten collaboration with providers to share clinical data that helps validate eligibility. About a fifth said they plan to enhance risk assessment and stratification to ensure current workflows accommodate new eligibility scrutiny. Finally, 17% said they plan to tighten data validation controls to improve management.

Payers also face increased interoperability and prior authorization mandates. These mandates are complicated by a lack of technology infrastructure to support them, a lack of internal IT services and limited EHR integration.

Payers said they plan to leverage AI to help automate approvals, as well as to increase staffing levels for utilization review and implementing real-time authorization tools.

Finally, payers are navigating policy and payment rules, which the report authors acknowledged frequently change. A quarter of payers said they lack the internal IT staff or resources to drive regulatory change management.

Rising healthcare costs continue to stress payers

Managing costs, projected to increase to $7.7 trillion by 2032, is the number one challenge for payers for the second year in a row.

Although the problem of mounting healthcare spending is not new, health plans intend to take enhanced action. About a third (34%) said they plan to automate manual processes with AI, while 27% intend to modernize or consolidate core administrative systems and another 26% plan to increase use of digital tools to engage members and providers.

Fewer said they will outsource shared services (7%) or restructure teams (6%).

Payers focus on member experience misalignment

Also on the agenda for 2026 are efforts to close the gap in member engagement and relationships. Currently, 76% of health plan executives said they think their members view them as a true partner in their healthcare journeys.

That's out of whack with reality, with a similar HealthEdge survey of consumers finding that only about half view their health plan as a true partner in their healthcare journey.

Payers need to close that perception gap, and they are foremost doing that by building out their member engagement technology suites. Around 6 in 10 will be investing in online scheduling systems this year, while 57% will enable personalized health and wellness recommendations and 53% will launch a mobile app.

Other priority member engagement tools include the following:

• Virtual concierge and patient navigation (44%).
• Digital health assessments (43%).
• Auto-adjudication for faster and more accurate claims payments (39%).
• Increased personalized healthcare via data sharing (38%).
• Enhanced and expanded member service centers (35%).
• Omnichannel flexibility and member portals (32%).

AI emerges as a technology salve

AI is rapidly becoming the top strategy for ameliorating payers' biggest pain points, the report revealed, signaling a shift in payers' overall technology priorities.

In previous years, payers were laser-focused on data security. In this year's survey, payers were less so interested in fortifying data protections, in large part because they have shifted their focus to safe and effective AI deployment (30%), technology modernization (20%) and seamless data exchange (12%).

Six in 10 respondents are automating manual processes with AI, machine learning or advanced analytics. They are also increasing their use of digital tools over the next 12 months to decrease spending.

Meanwhile, around half are applying AI or machine learning to avoid penalties associated with interoperability mandates and prior authorization requirements.

Payers eye collaboration to fix flagging payer-provider relationships

The rocky relationship between payers and providers in their network is a tale as old as time. Delays in claims processing (24%), delays in prior authorization decisions (21%), lack of self-service tools (15%) and limited real-time data access (15%) have historically gotten in the way of true partnership between payers and providers.

Heading into 2026, health plan executives are focused on driving collaboration with their provider partners, foremost by investing in the technologies designed to fix their biggest pain points.

For example, 22% are working to implement better payment integrity solutions to enhance payment accuracy. Ideally, this will reduce administrative friction and payment disputes.

Another 21% are modernizing their provider data platforms to enable accurate credentialing, faster onboarding and real-time directory updates. According to payer respondents, this will help providers resolve service-related questions quickly and better verify member eligibility.

Still, about a quarter of payers are using their contracting as a way to deepen collaboration with provider partners. Specifically, payers are responding by expanding provider collaboration and value-based contracting, which require strong data-sharing, insights into performance metrics and better alignment of incentives.

According to the report authors, supplementing technology investment with relationships will be critical to managing payers' biggest issues in the upcoming year.

"The next phase of payer evolution will hinge on collaboration among people, processes, and technology, with modernization efforts guided by data, trust, and shared outcomes," they concluded.

Sara Heath has reported news related to patient engagement and health equity since 2015.