Healthcare is constantly transforming, and payment integrity programs are facing unprecedented challenges fueled by rising medical spend, an evolving and unpredictable regulatory environment and increasing stakeholder expectations. These trends, coupled with a rapidly accelerating technology landscape, bring payment integrity to a critical inflection point.
We unpack these trends and the impact they may have on your payment integrity program. To dive deeper into the future of payment integrity, read our white paper: Getting started on your path to payment precision.
1. Rising spend and utilization
Increasing medical spend and utilization are putting pressure on health plans to drive ongoing payment accuracy and policy management, driven by:
- Aging population: From 2025-2030, the number of people 65 years or older is projected to grow by 12.41%.1
- Higher acuity: Chronic conditions are rising, with the percentage of 20–44-year-olds with obesity increasing from 32.7% to 40.9% from 2009-2020.2
- High-cost drugs: From 2021-2023, employer healthcare dollars spent on pharmacy increased from 21% to 27%.3
- Inflation: Healthcare’s growing as a share of gross domestic product, with medical inflation higher than overall inflation in June 2024.4
An older, sicker population that uses more expensive treatments, in addition to growing inflation, puts strain on health plans to find alternative ways to manage spend while maintaining access to care.
2. Shifting and unpredictable regulatory environment
Today’s environment is constantly evolving, and with a new administration, it’s challenging to know what the future looks like. Several areas to keep an eye on are:
- Price transparency: New regulations require health plans and providers to provide accurate pricing information before or at the point of care. Executive orders are also ramping up enforcement.
- Prior authorization reform: Prior authorizations are more regulated than ever, with a focus on minimizing provider burden and care delays and regulating the role of AI in coverage determinations. Health plans will need to consider reevaluating and prioritizing payment integrity interventions.
- Medicare and Medicaid uncertainty: Plans for spending cuts are underway, and they’ll likely focus on addressing fraud, waste and abuse in Medicaid. Other regulations include Stars ratings redistribution which could impact revenue and increase health plan financial responsibility for prescription drugs. With an unclear outlook for Medicare and Medicaid, plans should prepare for potential financial headwinds.
3. Increasing stakeholder expectations
Payment integrity interventions remain critical for health plans but are associated with increased member and provider abrasion. As the healthcare industry evolves, members and providers are demanding more from health plans. Members expect price transparency at or before the point of service.
Providers want more transparency into health plan claim requirements so they can submit claims correctly the first time, avoiding denials and delayed payments. They’re also looking for tools to help them manage payment integrity interventions.
Demands for more transparency upfront puts pressure on health plans to rethink the status quo of payment integrity. Plans should consider shifting interventions into the provider workflow to help providers submit claims correctly.
4. Evolving technology landscape
We expect advanced technology to play a significant role in modernizing and facilitating a more integrated healthcare payment ecosystem. It’s also raising provider expectations for quicker interactions that are further upstream in the claim lifecycle. Health plans should consider real-time interactions enabled by API-based data integrations, higher interoperability standards and real-time editing at claim submission.
With AI breakthroughs, organizations are exploring more effective ways to increase operational efficiencies. For example, providers are using AI to help submit claims, respond to denial letters and submit appeals—but others are using it to submit fraudulent claims.
Payment integrity teams are therefore considering using AI to help make interventions more targeted and precise, identify new sources of overpayments, enable higher quality and more consistent reviews, improve efficiencies and enhance experiences for all stakeholders.
A precipice of change
These trends are putting immense pressure on health plans to balance rising spend while mitigating abrasion. Emerging technologies have the power to make it possible, driving plans to reevaluate their approach to payment integrity. At Optum, we’re defining the future of payment integrity as payment precision—helping health plans achieve payment accuracy at claim submission.
Payment precision’s about facilitating correct, efficient and prompt claim submission from the start to help minimize downstream denials and delayed payments. The future of payment integrity is shifting interventions, such as edits, payment policies and more, into the provider workflow.
About Optum
Optum is a leading information and technology-enabled health services business dedicated to helping health plans achieve payment accuracy across the claim lifecycle. We’re helping our clients pay claims accurately and on time, the first time, and prevent denials to drive a more affordable healthcare system for everyone.
About Tisha Holden
Serving as Market President at Optum, Tisha has spent more than 25 years at the forefront of health plan innovation, helping clients build strategic, comprehensive programs to address their toughest challenges and achieve financial health and operational excellence at scale.
1 U.S. Census Bureau. 2023 National population Projections Tables: Main Series. 2023.
2 Aggarwal R, Yeh RW, Maddox REJ et al. Cardiovascular risk factor prevalence, treatment, and control in us adults aged 20 to 44 years, 2009 to March 2020. JAMA. March 2023.
3 2025 Employer Health Care Strategy Survey. Business Group on Health. August 2024.
4 How does medical inflation compare to inflation in the rest of the economy? Peterson-KFF Health System Tracker. August 2024.
