CEO.CA Chairman's Briefing

CMS compliance deadlines and heightened cybersecurity expectations are accelerating payer interoperability and utilization management modernization while shifting vendor selection toward platforms that measurably shorten time-to-treatment, close gaps in care, and improve quality performance.

WASHINGTON, D.C. / ACCESS Newswire / December 15, 2025 / The healthcare payer information technology (IT) sector continues to evolve rapidly, and 2026 is positioned to be a pivotal execution year for regulatory compliance programs and modernization roadmaps. Insights derived from Black Book Research survey findings of 1,158 payer IT and administrative users (Q2-Q4 2025) indicate that payer organizations are prioritizing investments that reduce administrative friction, strengthen cybersecurity posture, and operationalize consumer-grade digital access as federal requirements move from policy into measurable operational deadlines.

Across commercial insurers, Medicaid managed care organizations, Marketplace plan issuers, and Medicare Advantage (MA) plans, payer leaders are adopting advanced IT solutions to improve operational efficiency, strengthen member engagement, and sustain compliance amid a growing and shifting regulatory burden. In parallel, payer IT investment decisions are increasingly being tied to measurable patient impact, faster time-to-treatment, fewer avoidable care disruptions, improved chronic condition control, and stronger care coordination across settings.

Key Takeaways for 2026
• Compliance execution is converging with outcomes accountability: payer IT roadmaps are expected to be judged on both audit readiness and measurable improvement in access, continuity, and quality.
• Prior authorization and interoperability are moving from pilot programs to production requirements, with increased demand for standardized APIs, automation, and reporting transparency.
• Vendor demand is rising for platforms that convert regulatory mandates into operational lift-reimbursement intelligence, governance-ready automation, and interoperable workflows that reduce avoidable delays in care.

Key Regulatory Developments Impacting Payers in 2026

1. CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)
Mandate: CMS-0057-F expands interoperability obligations and adds standardized prior authorization (PA) process, reporting, and API expectations for impacted payers.
2026 Technology Focus:
• Operational readiness for PA process and reporting requirements effective in 2026, including decision timeliness, transparency, and public reporting workstreams implemented in ways that do not introduce new access barriers.
• Acceleration of FHIR-based interoperability infrastructure and API management to support required payer data exchange capabilities by 2027, with 2026 functioning as the primary build and production-hardening year for many plans.
• Patient access impact: payer modernization programs are increasingly expected to reduce avoidable delays in care and administrative rework for clinicians.
Vendor Opportunity Areas: Interoperability platforms; FHIR implementation services; PA workflow automation; API gateways/management; provider connectivity; member-facing digital access; and transparency measurement/reporting systems.

2. Transparency in Coverage (TiC): Schema Modernization and Prescription Drug Machine-Readable File (MRF) Direction
Mandate: Ongoing TiC requirements for machine-readable files (MRFs), with continued maturation of technical specifications and compliance operations.
2026 Technology Focus:
• Continued scaling of price transparency publishing pipelines, validation, and resilient hosting.
• Increased need for data normalization, schema migration tooling, and automated compliance QA as technical specifications evolve.
Planning Watch Items:
• Continued agency direction on prescription drug MRF requirements following recent federal requests for information and stakeholder input.

3. Advanced Explanation of Benefits (AEOB) Under the No Surprises Act
Mandate: AEOB requirements remain in ongoing rulemaking development rather than near-term enforcement.
2026 Technology Focus:
• Sustained demand for real-time benefits verification, cost estimation, and payer-provider data exchange capabilities.
• Architectural planning for AEOB generation workflows (provider data ingestion → benefit calculation → member communications).
Planning Watch Items:
• Timing of proposed and/or final AEOB regulations, compliance dates, and phased implementation requirements.

4. Medicare Advantage (MA) and Part D: Contract Year 2026 Policy and Technical Changes
Mandate: CMS finalized Contract Year 2026 policy and technical changes affecting MA and Part D operations, reinforcing ongoing compliance and reporting priorities for the 2026 benefit year.
2026 Technology Focus:
• Upgrades to regulatory reporting, quality measurement analytics, member communications, and oversight-ready operational controls.
• Continued emphasis on data integrity supporting risk adjustment, utilization management, and member experience programs.

5. HIPAA Security Rule Modernization: Proposed Federal Updates and Heightened Cybersecurity Expectations
Mandate: HHS OCR has advanced proposed updates to the HIPAA Security Rule, signaling substantial potential changes to required safeguards and compliance practices; finalization timing remains pending.
2026 Technology Focus:
• Accelerated investment in security risk analysis, encryption, access controls, audit readiness, and incident response tooling.
• Increased scrutiny of vendor risk, third-party controls, and security documentation.

Key Technology Developments Shaping Payer IT in 2026

• Prior Authorization Modernization at Scale: Compliance-driven workflow redesign and automation, with a shift toward standardized data exchange and measurable turnaround performance.
• Interoperability-by-Default Architectures: Expansion of FHIR-based API programs, identity matching, consent controls, and data governance to support member access and cross-entity exchange.
• Transparency Operations and Schema Readiness: Industrialized pipelines for MRF publishing, validation, and schema migration planning tied to evolving technical requirements.
• Cybersecurity as a Board-Level IT Program: Controls alignment, auditability, and security engineering investment anticipating tighter HIPAA expectations and continued breach risk.
• AI/ML Expansion Within Governance Guardrails: Increased use in fraud, payment integrity, utilization management, and member engagement-paired with stronger model risk management, explainability, and privacy controls.
• Outcomes-Driven Digital Enablement: Expansion of clinical-grade digital programs integrated into care management, aimed at measurable gaps-in-care closure, adherence improvement, and preventable utilization reduction.

Anticipated High-Demand Payer IT Platforms for 2026 Acquisition and Outcomes Improvement

In 2026, acquisition and strategic investment is expected to intensify around payer IT product categories that convert compliance into measurable clinical and financial impact. Buyers are expected to prioritize platforms that improve time-to-treatment, strengthen continuity of care, reduce preventable events, and support reimbursement intelligence across government and commercial risk portfolios. The most attractive assets will demonstrate scalable interoperability, governance-ready automation, and quantifiable improvement in quality, affordability, and member experience.

Priority Platform Categories
• Prior authorization modernization platforms that reduce cycle times, improve first-pass approvals, standardize rationale transparency, and support audit-ready governance.
• FHIR-native interoperability enablement (API gateways, consent/authorization, identity resolution, terminology services, developer tooling).
• Care management platforms that operationalize stratification into closed-loop outreach and document measurable impact (gaps-in-care closure, utilization reduction, adherence improvement).
• Medication access and specialty management technologies integrating PA, real-time benefits, specialty workflows, and affordability controls without compromising outcomes.
• Home-based care and remote monitoring platforms integrated with clinical response workflows (alerts that trigger interventions, not passive reporting).
• Cybersecurity and privacy engineering as continuity infrastructure (IAM, privileged access, auditability, third-party risk, incident readiness).

Opportunities for IT Vendors in 2026

Interoperability and Prior Authorization Enablement: FHIR and HL7 implementation services, API platforms, payer-provider connectivity, and utilization management modernization aligned to CMS-0057-F timelines.
Transparency and Consumer Cost Tools: MRF publishing automation, schema migration, data quality/validation, and consumer-facing cost estimators aligned to TiC evolution.
Cybersecurity, Compliance, and Audit Readiness: Security posture management, encryption, IAM, SIEM/SOAR, third-party risk, and compliance documentation platforms anticipating HIPAA modernization outcomes.
Medicare Advantage and Government Program Operations: Regulatory reporting, quality analytics, and operational platforms supporting Contract Year 2026 MA and Part D requirements.
Outcomes-Driven Enablement and Reimbursement Intelligence: Platforms that demonstrate measurable outcomes improvement and support oversight-ready reimbursement intelligence across MA, Medicaid, and commercial risk portfolios.

The healthcare payer IT market is expected to grow in 2026, driven by the transition from interoperability and prior authorization policy into compliance execution, the continued maturation of transparency infrastructure, Medicare Advantage operational changes for the 2026 benefit year, and intensifying cybersecurity expectations tied to HIPAA modernization. The most successful payer organizations and vendors will be those that align roadmaps to published compliance milestones while deploying outcomes-driven digital enablement that measurably improves access, continuity, and quality of care.

"Black Book's polling of 1,158 payer IT and administrative users shows 2026 buying decisions are shifting to a single test: solutions must be compliance-ready and outcomes-relevant," said Doug Brown, Founder of Black Book Research. "API-first prior authorization and FHIR interoperability are now production requirements, and payer leaders are prioritizing platforms that shorten time-to-treatment, close gaps in care, and improve medication access because those metrics drive member outcomes and total cost of care."

About Black Book Research
Black Book Research is a vendor-agnostic healthcare technology, services, and outsourcing research firm. Black Book publishes independent market intelligence based on validated user feedback and stakeholder surveys across healthcare delivery and payer organizations. Black Book's research is designed to provide objective insight and is not produced as vendor-sponsored editorial or paid advertising content.

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SOURCE: Black Book Research