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Rising costs. Relentless regulation. For health plans, the question isn’t whether these pressures are intensifying. It’s how to respond. According to new research from HealthEdge®, these twin forces are now driving some of the most difficult decisions health plan leaders have had to make in years.

Inside the Shift: Health Plans Are Rebalancing

The 2026 HealthEdge Annual Payer Report, The Great Rebalancing, reveals a health plan industry at an inflection point. Cost containment remains the top challenge for the second year in a row, but it’s now joined by a surge in regulatory demands—amplified by new legislation like the One Big Beautiful Bill Act (OBBBA) and shifting interoperability mandates.

The result? A landscape where strategic tradeoffs are unavoidable.

[“Health plans are being forced to make deliberate, and often difficult, decisions about where to invest limited resources, choosing between modernization and stability, innovation and affordability, automation and the human touch.”]

— The Great Rebalancing: Inside the New Realities Shaping Health Plan Performance 

Regulation: No Longer a Background Risk

According to the HealthEdge report, today’s compliance environment is unlike anything health plans have faced before.

• 85% of health plan leaders report that regulatory pressures are moderately or significantly impacting their costs and margins.
• The OBBBA introduces complex real-time eligibility rules and demands tighter oversight of enrollment processes, shifting long-held workflows practically overnight.
• Interoperability mandates tied to The Centers for Medicare and Medicaid Services (CMS) Final Rules require seamless, real-time data sharing between systems and stakeholders, or risk penalties and non-compliance.

Together, these changes have made regulatory readiness not just a legal necessity, but a core operational challenge.

Cost Containment: Still the Top Priority

At the same time, the cost curve continues to bend in the wrong direction.

Health plans are contending with shrinking margins, rising administrative costs, and ongoing pressure from stakeholders to deliver more value with fewer resources. According to CMS projections, healthcare spending in the U.S. is expected to exceed $7.7 trillion by 2032, far outpacing wage growth and inflation.

Internally, health plans report being squeezed on all sides:

• Providers are dealing with tighter reimbursement models and administrative burdens.
• Members are feeling the weight of higher out-of-pocket costs.
• Operations teams are battling outdated, siloed systems that drive up rework, delay decisions, and hinder scale.

In this climate, cost and compliance are no longer separate challenges. They are deeply interconnected and must be addressed.

What This Means for Health Plan Strategies in 2026

This year’s survey data makes one thing clear: health plans can’t do everything. Instead, they must rebalance priorities, shifting resources toward the capabilities that will yield the greatest impact in an era of mounting complexity.

That’s why many health plans are beginning to:

• Reevaluate legacy systems and workflows that drive hidden costs.
• Prioritize investments that enable real-time data sharing and operational visibility.
• Seek scalable operating models that can flex with regulatory change and business growth.

Finding Balance in the Storm

While there’s no one-size-fits-all solution, the next phase of evolution will depend on how well health plans align people, processes, and technology to respond to change without compromising compliance, service, or financial performance.

As The Great Rebalancing report notes, many health plans are rethinking long-held assumptions. Instead of layering new tools on top of legacy systems, leaders are focusing on connecting the capabilities that matter to unify data, streamline workflows, and enable smarter decisions in less time.

This is where technology modernization and new operating models like Business Process as a Service (BPaaS) can play a role—not simply as cost-cutting measures, but as strategic levers for agility, accuracy, and scalability. The goal isn’t to chase every innovation but to build the right foundation that enables health plans to respond faster to regulatory change, scale efficiently, and deliver the transparency members and providers expect.

Gain insights into what more than 550 health plan leaders are thinking and doing to rebalance their priorities in 2026 by downloading the full report or visiting www.healthedge.com.

 

The Transparency in Coverage (TiC) final rules of 2020 promised a revolution in healthcare price transparency. The vision was bold: empower consumers with data to drive competition and lower costs. Five years later, health plans are faced with an overwhelming amount of data, but not necessarily the actionable insights they need.

Hospitals alone generate more than 50 petabytes of data every year (about 50 million gigabytes). But because this is unstructured data and difficult to organize, 97 percent goes unused by hospitals and their partners.

Release of the Transparency in Coverage proposed rule (CMS-9882-P) marks a pivotal point for the industry. This isn’t merely a regulatory update—it’s a fundamental restructuring of the way healthcare organizations deliver pricing transparency. For health plan leaders, this moment demands a strategic shift from simple compliance to data stewardship.

In this guide, we offer a breakdown of the proposed changes and how healthcare payers can prepare.

The Data Deluge: Solving the Petabyte Problem

For health plans, the current system of data collection and management is buckling under its own weight. In-network rate files have ballooned to terabyte sizes, creating significant barriers:

• Files generated by payer systems are too large for most researchers and developers to process.
• Raw data lacks the context needed to understand the causes behind rate changes and other trends.
• Disconnected initiatives between hospital and payer transparency rules prevent meaningful cross-system analysis.

The proposed rule addresses these barriers directly, aiming to transform raw data into actionable intelligence.

Strategic Shifts: Key Changes in the Proposed Rule

The new proposed rule introduces transformative changes designed to make data more manageable and useful, if finalized.

1. From Monthly to Quarterly Reporting

The Change: Reporting for in-network rate files and out-of-network allowed amounts shift from a monthly to a quarterly cadence.

The Impact: This is intended to reduce the operational burden of file generation. It allows payer teams to focus on data quality assurance rather than constant production cycles. However, it may also introduce a lag in pricing visibility that could impact competitive strategy.

2. Network-Level Organization

The Change: Files must be organized by provider network rather than by individual plan.

The Impact: This helps eliminate data duplication for plans that share provider networks across multiple products. While this will significantly reduce file sizes, it requires a major architectural overhaul to aggregate data correctly. You will need to map your product portfolio against provider networks to ensure accurate enrollment reporting.

3. Contextual Intelligence: The “Legend” for the Map

The rule introduces new file types to provide critical context:

• Text File (within 7 calendar days of a change to any information): Includes the URL of the page hosting the machine-readable files, a direct link to the machine-readable files themselves, and contact information for the individual responsible for the machine-readable files.
• Change-Log File (Quarterly): Identifies changes from previous reporting period to current, allowing users to identify which files changed without downloading or analyzing all files.
• Taxonomy File (Quarterly): Standardizes how providers are categorized, based on internal organizational logic for matching services to specialties.
• Utilization File (Annual): Identifies which provider-service combinations actually occurred, eliminating “ghost” data.

These files assist with converting raw numbers into meaningful insights but could require payers to formalize and disclose internal processes that were previously proprietary.

4.  Exclude Clinically Implausible Rates

The Change: Machine-readable files must exclude provider-rate combinations where reimbursement is unlikely based on provider specialty.

The Impact: This approach is expected to help reduce file sizes and improve data quality by eliminating rate distortions from implausible combinations of provider specialty, billing code, and service rates.

5. Streamlining Cost Transparency: Harmonizing Duplicate Federal Requirements

The Change: Requires phone-based disclosures under the No Surprises Act to match the comprehensive information already mandated for internet tools under Transparency in Coverage rules.

The Impact: This consolidation is expected to eliminate regulatory redundancy while creating operational consistency for health plans and ensuring consumers receive equivalent cost-sharing information regardless of their preferred communication channel.

Strategic Action Plan: Preparing for Implementation

While the final rule is anticipated later in 2026, the complexity of these changes requires health plan leaders to take immediate action. Here are recommendations from HealthEdge® Regulatory experts:

Immediate Actions (Early 2026)

• Assess Network Structure: Map health plan products to provider networks immediately. Identify where reorganization is needed to meet the new disclosure requirements.
• Audit Taxonomy Systems: Review how internal systems categorize providers. Inconsistencies here will be exposed by the new Taxonomy File requirement.
• Analyze Out-of-Network Data: The proposed rule lowers the claim threshold from 20 to 11. Run scenarios on health plan data to see how this impacts disclosure volume.

Medium-Term Actions (Mid to Late 2026)

• Architect Your Data: Begin designing the infrastructure to aggregate data at the network level and track changes for the required logs.
• Prepare Customer Service: Design training programs for phone-based pricing support including scripted decision trees and quality assurance considerations.

The Opportunity in the Obligation

It is easy to view these changes as just another compliance hurdle. However, forward-thinking health plans will see the strategic opportunity. The organizations that thrive will be those that use this data not just to check a box, but to optimize network contracting, enhance employer relationships, and drive innovation.

By treating transparency as a core business asset rather than a regulatory burden, you position your health plan as a market leader. We must move beyond petabytes of noise to practicality and precision.

To learn more about the regulatory and cost pressures most heavily impacting health plan leaders, download the 2026 HealthEdge Annual Payer Report, “The Great Rebalancing: Inside the New Realities Shaping Health Plan Performance.”

About the Author:

Bettina Vanover, HealthEdge Regulatory Compliance Principal, brings over two decades of leadership experience in healthcare compliance, regulatory strategy, and government program oversight.  Her expertise spans enterprise risk management, audit readiness, and the integration of regulatory frameworks into scalable, tech-enabled solutions.

At HealthEdge, Bettina plays a pivotal role in shaping regulatory strategy. She helps ensure that our solutions empower payer organizations to meet evolving standards, while driving efficiency, transparency, and better care delivery.

Across the healthcare industry, organizations are making do with a payment integrity process that relies on a complex web of disparate systems, multiple vendors, and manual ticketing processes. This fragmentation creates administrative bottlenecks and leads to friction with members and providers.

When payment integrity operations are based on disconnected tools, health plans can find themselves stuck in a “pay and chase” cycle. In these cases, the lag between identifying a necessary policy change and actually implementing it can span months. Meanwhile, health plans are still processing incorrect claims, leading to burdensome adjustments. To meet industry demands and manage rising costs, health plans must shift away from this reactive approach.

Advanced payment integrity solutions like HealthEdge Source™ can enable health plans to centralize payment policies and integrate disjointed workflows, delivering production savings with unprecedented accuracy and efficiency.

The High Costs of Legacy Payment Integrity Systems

Current industry models for managing payment integrity are often inefficient. They were not built to handle today’s complex billing guidelines, or the speed required for modern claims processing. Legacy payment systems can prevent health plans from achieving true payment accountability in a few key ways, including:

1. Extended Edit Timelines

Moving a new payment policy edit from concept to production can take several weeks. Operations teams must wait for vendor engineering cycles or navigate internal IT backlogs. But claims continue to be invoiced and paid incorrectly in the meantime, requiring time-consuming and costly repayments.

2. Vendor Dependency

Health plans frequently rely on external vendor engineering teams and rigid release schedules across multiple, disparate systems. This limits a health plan’s control over the launch of critical payment updates.

3. Inflated Operational Costs

Managing multiple vendors and paying unanticipated fees for configuration changes can add significant administrative overhead for health plans, in addition to the time it takes to reconcile the data in each system.

4. Lack of Agility

The inability to respond quickly to new billing trends, regulatory updates, or contractual changes compromises a health plan’s ability to manage costs effectively. In a rapidly changing healthcare landscape, flexibility is a requirement, not a luxury.

User-Driven Configuration: The Future of Payment Integrity

To overcome traditional barriers to payment accuracy, health plans need access to integrated digital solutions that centralize processes and improve control. HealthEdge Source delivers robust configuration capabilities that empower users to build, test, and deploy complex edits immediately—no engineering change orders required. This shift puts control back in the hands of health plan leaders and facilitates data-driven decision-making.

With HealthEdge Source, teams can validate policies against real-world data, forecast financial impacts before deploying into production, and implement changes with precision.

The Four-Step Payment Integrity Workflow

HealthEdge Source integrates several powerful modules into a cohesive workflow known as the “virtuous cycle.” This end-to-end process covers ideation, testing, implementation, and analysis, ensuring accuracy while dramatically increasing the speed of deployment.

1. Test and Validate with What-If Modeling  

Before deploying a new edit, the Source What-If Modeling tool allows payers to forecast the impact of potential contract configurations using historical data. This predictive capability helps health plans create a data snapshot, run a data study to process the snapshot against different configurations, and analyze the outcome before going live.

2. Collect Real-Time Data with Monitor Mode 

Once an edit is built within HealthEdge Source, it can be activated in Monitor Mode. This feature runs the edit passively on live production claims without affecting final payment adjudication. The claim processes first with standard production edits, then runs a second time with monitored edits applied.

This allows teams to collect real-time performance data and continuously track the financial impacts of policies, building confidence in the accuracy of the edit through live-fire testing without financial risk.

3. Educate Providers with Informational Edits 

To minimize provider abrasion and encourage proper billing, HealthEdge Source users can temporarily set the disposition of an edit to “informational.” During a set period, such as a 90-day notification window, the edit returns a message on the Explanation of Benefits explaining the new policy.

This proactively educates providers on new guidelines, giving them time to adjust billing systems before the edit impacts reimbursement.

4. Automate Retrospective Analysis with Retroactive Change Management 

After an edit goes live, the Retroactive Change Management tool automates the identification of claims paid incorrectly prior to the change, which is critical for backdating policies or implementing contract updates.

The Retroactive Change Management tool can re-process historical claims against the new configuration and generate dashboards detailing overpayments and underpayments. This consolidated analysis streamlines recovery and facilitates transparent communication with providers regarding backdated changes.

Build Custom Payment Policies with Precision

The Advanced Custom Edit tool from HealthEdge Source allows payment integrity teams to design and implement highly specific policies tailored to unique plan requirements via an intuitive, point-and-click interface.

Building an edit requires three key components:

• Current Claim Criteria: Defines attributes of the incoming claim that qualify it for the edit.
• History Criteria: Defines specific patterns or codes to look for in a member’s claim history.
• Relational Criteria: Establishes the logic for how the current claim and historical claims interact to trigger a denial or flag.

For example, a plan could easily address “Lab Duplicates” where a facility bills for collecting a sample and an independent lab also bills for the test. The user can create an edit that identifies a facility lab claim and searches the member’s history for a matching service from an independent lab on the same date.

Future-Proofing Your Payment Integrity Strategy

Digital innovation isn’t about adopting new tools just for the sake of change. It’s about recognizing that health plans need a nimble digital ecosystem that can help payers adapt to change quickly, proactively avoid errors, and address root-cause issues quickly and easily.

HealthEdge Source enables an enterprise payment accountability approach, shifting focus from post-payment recovery to proactive cost avoidance. With the ability to continually adapt to both competitive market demands and evolving regulatory requirements, health plans can set new standards in transparency, accountability, and operational excellence.

Transforming your claims process starts with taking control of your data. By adopting high-speed, proactive payment integrity solutions, your organization positions itself for long-term success and industry leadership.

Watch the full webinar on-demand to learn more: “High-Speed Payment Accuracy: Take a Proactive Approach with HealthEdge Source.”