Beyond Disruption: 5 Strategies Every Health Plan Needs for 2026

When industry disruption is constant, your strategy needs flexibility. Here’s what successful payment integrity leaders are doing now to prepare for 2026.

It’s strategic planning season again. As the weather cools down and budget cycles heat up, health plan payment integrity leaders are taking stock of where they’ve been and where they’re going. But the context looks very different than it did even last year.

Administrative costs are rising, vendor contingency fees are consuming double-digit percentages of payment integrity savings, and the regulatory environment is volatile. At the same time, the shift to prepay is happening at twice the rate of post-pay, and AI adoption is rewriting how work gets done.

The question is no longer whether disruption is coming. It’s already here. The challenge for payment integrity leaders is how to prioritize investments, align people and processes, and create flexibility to thrive in this environment.

Here are five focus areas to check your 2026 strategic plans against:

• • Start with last year’s plan and measure impact with data to position for your next building block
  • Keep long-term plans flexible — but prepare for macroeconomic and legislative shocks
  • Avoid the pitfalls of short-term “vendor-first” thinking
  • Prepare for continuous innovation cycles — especially AI and automation
  • Master two essential leadership skills: Change management and ecosystem collaboration

Let’s get into the details, including how some of the top leaders in the industry are thinking about the future of their programs.

1. Start with last year’s plan, measure impact with data, position for your next building block

Your 2025 PI program results provide the clearest guide for 2026 priorities. As you gather data for year-end program reporting, note the broader story it tells. Use key anecdotes to illustrate success and gaps alongside measuring your impact in terms of avoided vs. recovered dollars, administrative costs saved, and speed to savings.

Benchmarks to consider:

• What percentage of total PI savings came prepay vs. post-pay?
• How much did vendor contingency fees consume?
• What is your average ROI on internalized PI activities vs. outsourced functions?

Industry benchmarks can help you put your performance in context. At the 2025 Power of Payment Integrity Conference, ClarisHealth revealed data that points to 5.6% savings as a share of medical spend and a 61.9% prepayment recovery rate as achievable targets.

Comparing your program’s results against these peer-led standards can surface blind spots, ensure your planning process is grounded in data-driven expectations, and strengthen your case for investment. And PI leaders who can track these metrics in real time are better positioned to set targets and demonstrate business value.

2. Keep long-term plans flexible — but prepare for macroeconomic and legislative shocks

Maintaining flexibility in strategic plans is critical. But the forces shaping health plan strategy now go beyond the incremental CMS rules of years past.

Combined with CMS initiatives to pilot tech-enabled prior authorization and pre-payment review, the One Big Beautiful Bill Act’s eligibility and payment reforms will materially affect claims volumes, denials, and post-payment recoveries. All of which will increase retroactive eligibility reviews, denials risk, and administrative burden for PI teams. At the same time, persistent inflation, rising medical costs, and pressure on administrative spend are forcing hard choices.

In this environment, health plans need flexible strategies that anticipate both regulatory disruption and macroeconomic volatility. Modular PI platforms, scalable data infrastructure, and operating models that can pivot quickly are no longer nice-to-haves. They’re essential to managing cost pressures while staying compliant.

3. Avoid the pitfalls of short-term “vendor-first” thinking

In the past, short-term thinking meant sticking with legacy technology and manual processes. 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

Many health plans are now internalizing PI functions and investing in technology to manage vendors more strategically. The payoff: greater cost control, better data access, and improved provider relationships.

4. Prepare for continuous innovation cycles — especially AI and automation

Innovation cycles aren’t theoretical anymore — they’re here. In 2025, PI programs are using:

• Generative AI to accelerate claims coding and medical records reviews and detect new anomalies.
• Prepay-first operating models to stop leakage before payment.
• Cloud-native PI platforms that integrate operations seamlessly across vendors and data sources.

Success requires more than technology. PI leaders should prioritize:

• Workforce readiness — training staff in data literacy and AI oversight.
• Dynamic data governance — managing quality, security, and FHIR-based interoperability.
• Risk management — anticipating how AI, automation, and new payment models affect compliance exposure.

5. Master two essential leadership skills: Change management and ecosystem collaboration

The human side of PI transformation is just as important as the technical side. Leaders must act as change agents — guiding staff through AI adoption, new workflows, and evolving job responsibilities.

Equally important is cultivating a community mindset. Health plans can’t solve PI challenges in isolation. Peer benchmarking, provider partnerships, and co-development with vendors are becoming essential to tackling fraud, waste, and abuse at scale.

Looking Ahead

Preparing for 2026 means more than adjusting budgets. It requires a commitment to measure impact, build flexibility, reduce dependency on costly models, and embrace innovation responsibly. Health plan payment integrity programs that internalize capabilities while strengthening collaboration across the ecosystem will lead the way in cost containment and stakeholder trust.

Disruption is no longer on the horizon for our industry. It’s the daily environment we operate in. The winners will be those who make strategic planning a living, adaptive process rather than a once-a-year exercise.