4 Emerging Healthcare Regulatory Trends in 2025 and Beyond

Navigating healthcare regulations and compliance is an intricate challenge. To optimize the use of healthcare dollars and more effectively address population health, The Office of the National Coordinator for Health Information Technology (ONC) is passing regulations to support the improvement of interoperability and prior authorization operations. To comply with these new rules, health plans are turning to advanced, integrated technologies.

This forward-looking blog dives into the most compelling regulatory trends of 2025 and changes on the horizon, offering actionable insights to help organizations adapt and thrive. By the end of this post, you’ll better understand what’s coming and how you can actively prepare your team and strategies.

Trend 1: Interoperability Redefines Healthcare Connectivity

Across the healthcare industry, siloed health information prevents health plans and providers from anticipating member needs and offering proactive interventions. In the years since the COVID-19 pandemic, the healthcare industry has seen more widespread use of digital health tools, and the integration of these tools into care management.

For health plans, leveraging Fast Healthcare Interoperability Resources (FHIR) offers a path forward—but adoption won’t be without challenges.

Key Interoperability Milestones

2025 is shaping up to be a critical year for assessing improvements in interoperability and payer technology adoption as part of regulatory trends in 2025.

By January 2027, APIs (Application Programming Interfaces) facilitating real-time data exchange between patients, providers, and payers will become enforceable, setting a new standard for seamless information sharing.

The Problem With Siloed Data

The lack of accessible, unified healthcare data presents hurdles to both operational efficiency and patient care. Without an intentional focus on interoperability, the growth of technology use at health plans and for members can lead to internal data silos. By themselves, these pockets of information can’t tell the whole story—but collectively they could help health plans and providers better understand and anticipate the needs of various populations.

How to Prepare:

• Partner with vendors offering FHIR-compliant APIs to centralize your data strategy.
• Conduct annual interoperability assessments to ensure systems are scaling effectively to meet compliance.

Strategic Advantage of Interoperability

Beyond mere compliance, interoperability lays the groundwork for comprehensive analytics and improved member engagement, making it a long-term investment in competitive differentiation.

Trend 2: Modernizing Prior Authorization Processes

Another significant aspect of regulatory trends in 2025 is the modernization of prior authorization processes. Prior authorization workflows remain outdated, heavily paper-based, and inefficient. The lack of electronic communication not only delays care but also wastes resources for providers and payers.

Key Prior Authorization Milestones

• 2025 will serve as a prep year as health organizations monitor the progress of prior authorization improvements ahead of finalized enforcement in 2027.
• 2026 will focus on API development tailored to new advanced Explanation of Benefits (EOB) regulations.

Shifting Toward Real-Time Decisions

Mandatory FHIR APIs and shortened authorization turnaround times will accelerate data tracking and approval workflows. However, many organizations remain underprepared for these rapid shifts.

Solutions to Consider:

• Equip your team with tools that support real-time communication between health plans and providers.
• Invest in AI-powered automation to process authorizations quickly and with greater accuracy.

Long-Term Impact of FHIR APIs:

Payers aligning their tech stack with FHIR standards stand poised to rapidly enhance provider relations, reduce administrative costs, and ultimately deliver better member experiences.

Trend 3: Data Privacy and Artificial Intelligence (AI)

The increased adoption of disparate technology systems leaves the door open for data privacy and security risks. But AI is entering the healthcare regulatory space, revolutionizing how fraud, waste, abuse (FWA), and early spending trends are identified. Health plans can leverage AI features like predictive analytics and natural language processing to identify waste and potential fraud—leading to cost savings and fewer manual reviews.

Privacy Implications

With healthcare data becoming more interconnected and accessible, regulations must evolve to protect sensitive information from breaches. Health plans must address questions such as:

• Where is sensitive health data stored?
• Who can access specific data?
• How long is the data protected once shared externally?

To maintain data security, health plans can invest in data encryption and cybersecurity infrastructure for their entire organization. They can also help ensure compliance readiness by adopting technology solutions with natively embedded data security and privacy measures.

Opportunities With AI:

Beyond security concerns, AI presents tools for streamlining compliance processes, enhancing analytics-driven strategies, and improving fraud detection. Read our recent blog to see 6 key ways AI can improve payment integrity at your health plan.

Trend 4: Transparency and Enrollment Regulation

Increasing regulatory scrutiny on enrollment and data collection procedures demands health plans revisit how they handle and present information to consumers. Advanced Explanation of Benefits and the No Surprises Act are paving the way for heightened transparency in billing and claims processing.

Upcoming Transparency and Enrollment Guidelines

• Automated Solutions for Comprehensive Enrollment Oversight.
• Addressing redundancies to streamline enrollment workflows.
• Clarity on AI’s role in administering and standardizing enrollment regulations.

Supporting Health Equity

Regulation updates also emphasize reducing barriers to care—be it geographic, financial, or systemic. Responding proactively and fostering a “patient-first” approach will be integral for retaining member trust.

Action Plan for Health Plan Executives

Invest Early in Innovation

Whether you’re considering the latest FHIR API or exploring AI-driven fraud detection, early adopters will capitalize most effectively on these opportunities.

Build Strong Vendor Relationships

Strong partnerships with tech providers will ensure efficient deployment of compliant solutions, keeping operations well ahead of evolving regulations.

Develop a Long-Term Roadmap for Readiness

Map out regulatory milestones through 2028, with annual evaluations to ensure progress toward compliance and interoperability goals.

By taking a strategic, forward-looking approach, organizations can transform compliance into an operational strength.

Driving Progress through Proactive Adoption

The future of healthcare compliance lies in proactive innovation. The regulatory changes on the horizon offer payers a unique opportunity to reimagine processes, adopt cutting-edge technology, and position their organizations as leaders in the industry.

By prioritizing interoperability, leveraging AI responsibly, and addressing the critical areas of data transparency and security, health plan leaders can achieve more efficient operations while keeping patient outcomes at the center of their strategies.

Want to stay ahead of regulatory trends in 2025 and maintain your market position? Download the complimentary HealthEdge Annual Payer Market Planning Report 2025.