8 Priorities for 2027 Payment Integrity Strategic Planning

Payment integrity strategic planning today requires a mindset shift as PI becomes integrated into organizational strategy. As PI leaders plan for 2027, here’s what they’re looking at.

Annual strategic planning for payment integrity requires more than a “rinse and repeat” approach. The industry continues to change dramatically: Affordability pressure has intensified, AI is affecting behaviors on both sides of the payer-provider relationship, and PI is accelerating its transformation into an enterprise capability, not just a back-office function.

As a result, the focus of PI program strategic planning is shifting from planning a better payment integrity program to planning a more adaptive, technology-enabled payment integrity organization. Our conversations with PI leaders at the Power of Payment Integrity conference in April reinforced this insight. They revealed eight major themes shaping their strategy for the upcoming year:

1. Affordability as a key business driver
2. A more strategic approach to AI
3. AI on both sides of the table
4. Provider collaboration for upstream savings
5. Organizational agility
6. Cross-functional governance
7. Platform standardization
8. Executive visibility into PI

Let’s take a look at each of these themes in more depth.

Affordability as a Key Business Driver​

Across conferences and our interviews with leaders, virtually every discussion comes back to affordability. Healthcare costs are set to rise yet again next year, with nearly half of U.S. adults blaming corporate health insurance companies for increases in care.

That disruption to healthcare economics puts payers under extraordinary pressure to cut costs.

“We’re passionately focused particularly on savings, to a degree that I haven’t seen in the last three years.”

— Susan Luden, Director of Financial Investigations & Provider Review, Highmark Inc.

But PI has more levers to pull in this initiative than just identifying and recovering overpayments. Instead, payers should be integrating PI operations to align with strategies for improving administrative efficiency, preparing for scale, demonstrating value to employers and members, and strengthening payment policy.

A Strategic Approach to AI​

PI leaders are no longer asking, “Should we use AI?” The question has shifted to, “Where should we implement AI first?” Identifying the most pressing business needs can help organizations figure out where AI can offer the most value, like replacing manual and repetitive work, instead of getting caught up in the hype and using it for its own sake.

In addition, there are governance and technical questions around AI that organizations must consider, such as:

• Which decisions still require expert review?
• What data infrastructure is required?
• How will we handle governance?
• How will provider AI impact our strategy?

While the role of AI in healthcare is evolving, the opportunities it presents continue to generate excitement.

AI on Both Sides of the Table

As scrutiny on medical spend increases across the organization, PI leaders are increasingly focused on providers adopting AI, especially for medical coding and billing. This trend has spawned some new behaviors, including positioning billing as a new source of revenue, which may be one of the factors driving up health care costs.

To prepare for this reality, PI leaders should explore questions like:

• • How will providers use AI?
  • What new billing behaviors will emerge?
  • Which payment policies might become outdated?
  • Which contract terms need revision?
  • What new monitoring capabilities are required?

Provider Collaboration for Upstream Savings

Five years ago, many health plans saw PI’s primary contribution solely as maximizing overpayment recoveries. Today, as medical and administrative cost pressures intensify, leaders see more opportunities in working with providers to identify the root causes of overbilling for more efficient billing practices overall.

One particular focus is shifting savings upstream. While prepay cost avoidance has long been a tactic to capture savings, plans are now looking at pre-submission as a growing area of focus. Payers are also investigating how to make those savings more visible to internal stakeholders as well as providers and members.

Organizational Agility

As the healthcare environment continues to change quickly, the ability to adapt quickly is as critical as meeting financial goals — and serves as a means to achieve them.

Instead of simply adding staff, PI leaders are looking for efficiencies that enhance agility, such as reallocating resources, reducing manual work with automation and AI tools, and reorganizing teams to better align with organizational priorities. These moves support the flexibility to keep up with a rapidly shifting landscape and can even potentially give organizations a competitive edge.

Cross-functional Governance

As payment integrity planning shifts from a back-office function to a capability supported by and benefiting the entire enterprise, processes can no longer be confined to departmental siloes. Planning and initiatives increasingly require input and decision-making from leaders across the organization, including:

• • Contracting
  • Provider relations
  • Utilization management
  • Legal
  • Compliance
  • Claims
  • Data/IT

Developing these cross-functional teams creates a more integrated approach to payment integrity, ensuring PI initiatives are aligned with broader organizational priorities.

Platform Standardization

Many PI leaders increasingly see the value in industry standardization around cost avoidance, savings measurement, and reporting. This could make efforts related to benchmarking, technology investment and executive communications easier.

PI leaders should also consider internal standardization of operational decisions to reduce variation, improve consistency and create a foundation for automation, analytics, and AI.

Executive Visibility Into PI

As PI moves from operational reporting toward enterprise performance management, executives need to see the value of this approach. PI leaders should identify and incorporate mechanisms, tools  and measurements that can demonstrate savings and other wins. These can include defining operational KPIs and metrics that show reductions in administrative costs, increased productivity, the ROI of AI tools and the impact on providers.

Providing executives with access to dashboards and reports helps them see progress and improvement, enhances communications and clarity, and helps build support for ongoing PI initiatives.

Your 2027 PI Strategic Planning Checklist

Here are 10 questions every payment integrity leader should answer before finalizing their strategy:

1. Are we solving for strategic cost containment, not just recoveries?
2. Which work should AI own in the next 12 months?
3. How will provider AI change our payment integrity strategy?
4. Where can we move upstream — from post-pay to prepay to pre-submission?
5. Which manual processes should disappear?
6. Are our teams organized for agility rather than volume?
7. Which functions should be included in payment integrity governance?
8. How will we strengthen collaboration with providers while maintaining accountability?
9. Are our savings definitions and reporting standardized enough to support executive decision-making?
10. What capabilities do we need to build now to prepare for the next three to five years?

Building a Foundation for 2027

Nothing stays the same, but the rate of change in the healthcare industry and its effect on payment integrity programs is definitely accelerating. PI leaders who are aware of the major concerns and issues they face — including affordability concerns, the impact of AI and a growing need for internal and external collaboration — can proactively prepare for them.

Developing organizational agility and ensuring executives see the effects of PI transformation will help navigate this environment — not  just next year but for years to come. Talk to ClarisHealth about how the Pareo® payment integrity operations platform is helping health plans stride confidently into an uncertain future.