2026 Payment Integrity Technology Trends: The Shift From Savings Engine to Enterprise Control

What’s on the horizon for healthcare payer technology in 2026—and why payment integrity is emerging as a core enterprise control function amid rising cost pressure, AI acceleration, and market uncertainty.

In 2025, the pace of change in healthcare accelerated once again: rising medical costs, rapid AI adoption by both payers and providers, legislative complexity, and continued consolidation. Health plans that stayed anchored to long-term strategy—and invested deliberately in technology—proved more resilient than those chasing short-term fixes.

If your health plan is like many others, you may be strengthening your payment integrity strategic planning efforts accordingly to prioritize smart investments that drive cost savings and growth.

To that end, we gathered insights from industry thought leaders and our internal experts on the industry’s growing interest in and adoption of technology – and what that means for payment integrity’s strategic direction.

The Macro Driver: Payment Integrity’s Moment Has Arrived

For years, payment integrity (PI) lived in the background, important but often misunderstood. A necessary safeguard. A recovery engine. But not necessarily central to core operations.

That era is ending. With medical loss ratios in the 90% range, regulatory complexity increasing, and provider-side AI use on the rise, margins are under pressure. And administrative cost is no longer a back-office concern — it’s an enterprise risk.

This shift is pushing PI into a new role: an enterprise control function that protects accuracy, resilience, and trust across the payment lifecycle.

“Payment integrity leaders need to focus on how to be as administratively efficient and nimble as possible. No matter the specific strategy, that adaptability to quickly changing market conditions needs to be there.”
Director Payment Integrity, Regional Blues Plan

As a result, PI leaders are looking beyond recovery totals and toward how well their operations can absorb change without breaking:

• • Can it reduce administrative cost?
  • Can it scale?
  • Can it keep up with a healthcare system that’s changing faster than ever?

Our conversations with payment integrity leaders, operators, and strategists reinforced this theme and underlined its strategic importance. PI as an enterprise control function stabilizes operations, surfaces risk earlier, and helps plans make smarter, faster decisions.

“PI has that rare ability right now to cut administrative cost and impact medical spend. That combination matters in this market.”
Sara Thomas, VP Growth Strategy, ClarisHealth 

The following three trends define how that shift is taking shape—from reactive recovery to proactive, enterprise-wide control. And what PI leaders should do now to succeed in 2026 and beyond:

1. Operational Excellence Becomes the Prerequisite for Innovation
2. AI Shifts from Hype to Normalized Infrastructure
3. Provider AI Adoption Drives New Billing Risk

Trend #1: Operational Excellence Becomes the Prerequisite for Innovation

After years of chasing point solutions and tactical gains, health plans are refocusing on something far more foundational: operational excellence.

Many PI teams are still managing hundreds of millions of dollars in savings and at least three vendors through fragile workflows: manual processes, disconnected systems, and institutional knowledge locked inside spreadsheets or individuals nearing retirement.

But as Sara Thomas so succinctly put it, “You can’t innovate on a house of sand.”

“You always need to be looking at do you have the best tech stack for where you want to take your business? And are the partners you have engaged continuously innovating and staying current?”
Kimberly Fadden, VP Client Engagement, ClarisHealth

These issues have long been simmering in the background. What’s new is the urgency. Workforce turnover, cost pressure, and growing scrutiny from executives and ASO clients are forcing plans to confront operational risk head-on. Initiatives to reduce “swivel chair” work, streamline workflows, and standardize PI operations are no longer optional—they’re prerequisites for scale.

Why it matters

Operational excellence is about resilience as much as efficiency. Without a stable operational backbone, every new initiative—AI, analytics, provider strategy—adds complexity instead of value. Worse, it creates single points of failure that expose plans to financial and compliance risk.

What PI leaders should do now

Evaluate outsourced partnerships for value and risk

Today, even with modern technology in place to manage PI operations, programs still may be over-relying on outsourced vendors paid on contingency. While contingency models can deliver quick recoveries, they come at a cost:

• • Hard costs: 15–20% in fees, plus $100k in setup and $10–40k annually for each vendor integration.
  • Soft costs: The perception of spending outsized administrative costs on preventable overpayments.
  • Strategic risk: Relying on multiple vendor point solutions may increase likelihood of savings gaps and provider abrasion. Being overleveraged with any single service vendor also may be a risk, in light of increased market consolidation.

This line item is too big to bet on vendor innovation as a given. Seek out vendors that prioritize transparency, and put processes in place that allow you to evaluate cost-to-value ratios across all outsourced efforts as well as quickly shift vendors to their greatest value position.

“Technology isn’t replacing the human in the loop—but it should stop making that human the single point of failure. One platform driving insights and data, using vendor partners to help drive innovation, and taking advantage of integrated AI is the key to payment integrity operational success.”
Tom Noack, SVP Product Strategy, ClarisHealth 

Break down functional silos across the PI lifecycle

AI-driven billing behavior, faster cycles, and higher stakes are turning departmental silos into operational emergencies. Disconnected systems and handoffs translate directly into lost dollars, strained provider relationships, and missed opportunities to intervene earlier.

Audit where institutional knowledge lives—and where risk concentrates. Leaders should treat integration as a risk reduction strategy and invest in platforms and processes that reduce dependency on individuals while connecting prepay and post-pay, insourced and outsourced efforts and insights. According to Tom Noack, at least 70% of edits can be moved prepay, and our own research shows cost avoidance now accounts for at least 60% of PI savings.

“Policy drives PI, but policy analysis happens outside of PI. PI needs to think broader than overpayments.”
Novelette Wallace, Head of Payment Integrity, Johns Hopkins Health Plans
From “Leveraging Medical & Payment Policy to Strengthen Payment Integrity and Drive Savings” session at NHCAA Annual Training Conference 2025

Treat operational modernization as a strategic enabler, not a cost center

Visibility brings opportunity but also scrutiny. PI must perform as reliably as any other core function. Translate PI outcomes into enterprise language and larger cost and growth initiatives executives care about. Use momentum to modernize—not just expand. Savvy organizations are increasingly pursuing industry-standard enterprise technology platforms that reflect best practices and offer scale with predictable, subscription-based costs.

The market lacks an array of enterprise technology options that payers can drive for payment integrity specifically. But a commercial solution that emphasizes industry standards, streamlines data sources, builds empathy with stakeholders, improves efficiency and reduces team frustration will pay dividends.

“Standard workflows working off industry best practices allow for scalability. So if you identify something you need to start reviewing, you can easily adapt to that. Versus having to wait months or a year when the opportunity has passed.”
Stephanie Gibbons, VP Payment Integrity Operations, ClarisHealth 

Trend #2: AI Shifts From Hype to Normalized Infrastructure

The AI hype in payment integrity is cooling—and that’s a good thing.

Rather than sweeping automation or claims review replacement, AI is settling into more practical roles: inventory management, workflow orchestration, prioritization, and insight generation. Less sizzle. More plumbing.

According to a recent industry survey, 80% of payers have an AI strategy in place or in development, reflecting a shift from broad exploration to focused execution. But most health plans today are still in experimentation mode with AI: running pilots, proofs of concept, or narrow use cases rather than scaled deployments.

In payment integrity, these solutions are focused on identifying billing patterns or segmenting provider behavior. These efforts are promising but still early.

Why it matters

AI that’s layered onto broken workflows increases administrative cost and complexity. Several leaders noted that, so far, AI hasn’t reduced admin spend—it’s often done the opposite.

When AI is positioned as a silver bullet, expectations quickly outpace reality. Normalized, assistive use cases deliver steadier—and more defensible—returns.

“We’re trying to find how we use AI to redefine the work we do. Improving identifications, validations, and contract and policy analysis.”
Novelette Wallace, Head of Payment Integrity, Johns Hopkins Health Plans
From “Leveraging Medical & Payment Policy to Strengthen Payment Integrity and Drive Savings” session at NHCAA Annual Training Conference 2025

Innovative PI leaders are thinking about concrete use cases beyond standard admin efficiencies like faster record reviews and toward capabilities to shift the industry forward:

• • Normalize inventory management
  • Support provider discussions
  • Cross-reference policy manuals and find other resource materials to help support a specific position or payment policy
  • Recommend claims with high potential for overpayment prevention or recovery

“In 2026, AI is going to show real practical impact on selecting claims with high overpayment potential and checking records against payer payment policy.”
Tom Noack, SVP Product Strategy, ClarisHealth 

What PI leaders should do now

Anchor AI initiatives to specific operational outcomes, not abstract potential

Define success metrics before deploying AI. Be realistic about timelines and value realization. And put in place the connective tissue — orchestration, observability and change management — that let your data and modern AI models make an impact. Without these foundations, even the best models stay trapped in proofs of concept rather than driving outcomes.

Normalize AI as infrastructure—not a silver bullet

Fragmented data, brittle processes, governance hurdles and legacy workflows put up barriers that AI can’t yet flow through – increasing administrative burden in the process. Prioritize platforms that integrate end-to-end and support long-term operational stability. As AI becomes increasingly embedded in clinical and operational workflows, it’s essential to clearly document and communicate when AI is used, how it influences data, and what models are behind it. Transparency is foundational to trust, accountability, and safe AI adoption in healthcare.

Hone your sense of vendor discernment

The surge of interest in AI has attracted a flood of new vendors into the PI space—some thoughtful, others opportunistic. Misaligned technology choices lock plans into complexity just as agility becomes critical. Apply rigorous diligence to your evaluation process; do POCs, collaborate with your peers, and talk with other clients of the vendor to fully interrogate the vendor claims and determine potential effectiveness for your own organization.

“There are a lot of vendors introducing new AI capabilities for payers, and it’s hard to know which one is going to be the right fit for you, which is highly dependent on your goals. And if you’re going to have multiple scenarios within the workflow where you’re introducing AI technology capabilities, you really must closely monitor the outputs with integrated reporting and trend analysis.”
Stephanie Gibbons, VP Payment Integrity Operations, ClarisHealth 

Trend #3: Provider AI Adoption Drives New Billing Risk

While payers debate AI strategy and pilot models, providers are already moving fast.

One of the most consequential shifts heading into 2026 is happening outside the health plan. Provider adoption of AI tools—particularly AI scribing with embedded coding recommendations—is already changing billing behavior.

AI-powered clinical documentation and scribing tools are being rapidly adopted—and providers love them. In at least one survey, one-in-five providers are at full rollout and another two-in-five in pilot.

But those same tools are beginning to influence coding behavior, documentation depth, and billing volume. Several leaders noted early signals of increased coding intensity tied to AI-assisted workflows, creating new pressure upstream for payment integrity teams.

“We’ve seen claim spend increase significantly since 2024 – largely due to increased coding intensity. AI scribes are capturing the patient encounter, sometimes including less relevant details that aren’t clinically important.”
Kurt Spear, VP of FIPR, Highmark
From “Generative AI in FWA” panel at NHCAA Annual Training Conference 2025

Why it matters

This isn’t a future-state issue—it’s unfolding now. AI is scaling behavior faster than humans ever could, amplifying both accuracy and error. The result: more complex claims, more nuanced disputes, and greater financial exposure if PI capabilities can’t keep pace.

“Providers are starting to source their billing and coding more to revenue cycle companies. And that creates another intermediary between the payer and the provider. It creates potentially more friction.”
Director Payment Integrity, Regional Blues Plan 

AI expands PI’s scope rather than shrinking it. Coding intensity and behavioral variation increase demand for accurate, coordinated controls.

What PI leaders should do now

Strengthen collaboration across the enterprise

PI, provider relations, policy, and analytics should all be working together in this new paradigm of increased coding intensity. This includes joint evaluation – and potential adjustment of – payment and reimbursement policies. The result is airtight logic for greater defensibility to bolster your position and provider communications.

Adapting policies and renegotiating rates also can help maintain financial stability in response to more accurate billing. There’s also a need to proactively educate providers on AI-enabled tools used by the payer. The goal is to reduce payment denials, recovery confusion, and ultimately, contention. Collaboration is the crucial component of balancing innovation with payment accuracy.

Monitor billing patterns for AI-driven shifts, not just traditional outliers

Provider billing errors coming from AI revenue cycle tools aren’t necessarily malicious but rather an unintended consequence of contextual failures: adult criteria applied to pediatric cases, complexity inflated by misinterpretation, and others. And traditional rules engines are struggling to meet the moment. Analytics should be refined to distinguish between coding, rule, and behavior-based changes.

Prepare for PI workload growth, not contraction

With payment integrity administrative expenses for recoveries adding up to as much as $50 per claim and pre-payment vendor contingency fees reaching an all-time high, health plans are increasingly looking to cost-avoiding claims overpayments with their own auditor resources. However, they often lack the analytics capabilities, program insights, and operational workflows to pursue this strategy efficiently.

Technology capabilities have progressed to overcome this barrier. Instead of requiring months to build new prepay edits while relying on resources outside of the payer’s control, natural language inputs streamline edit design and testing to improve agility and make the most of limited resources. By some estimates, internal prepay claims validation costs 3x less than vendor post-pay efforts.

“For many years, payment integrity has been a game of whack-a-mole, but that’s no longer sustainable. It behooves all of us to find opportunities to partner with our providers to review records and billing behaviors using a single source of truth.”
Director Payment Integrity, Regional Blues Plan 

What This Means for 2026

Payment integrity is entering a defining phase. Plans that view PI as a strategic lever and build resilient operations are pulling ahead—while others remain stuck treating it as a cost or a symptom.

The difference often comes down to leadership: experienced, tech-savvy PI leaders who can articulate value and seize the moment to earn their seat at the enterprise table.

The leaders who succeed in 2026 won’t be the ones chasing the loudest trends and flashiest technology advancements. They’ll be the ones who positioned their programs for scale, integrated their capabilities, communicated their insights across the enterprise, and approached innovation with discipline and curiosity.

“Avoid the temptation to view your PI strategy in black-or-white terms. It’s prepay and post-pay, insourced and outsourced, AI and human ingenuity. Thinking in terms of both/and rather than either/or will allow you to maximize opportunity.”
Jeff McNeese, CEO, ClarisHealth

Extending your competitive advantage requires more than chasing trends. It requires a control framework that can absorb change without breaking.

Fortunately, a comprehensive technology platform like Pareo® allows health plans to harness the power of A.I., scale and improve processes, decrease costs, and accelerate ROI.

In a system where behavior can’t be controlled—and AI is accelerating everything—payment integrity remains one of the few value levers health plans truly have. The question isn’t whether PI matters. It’s whether it’s ready.

Talk to ClarisHealth to explore how Pareo supports payment integrity programs that are evolving into enterprise control functions—ready for 2026 and beyond.