The Influence of Regulatory Requirements and Evolving Reimbursement Models on Health IT Strategy for Payers and Providers

As with all healthcare topics, the topic of payers and providers is very complex and multifaceted. So today, we are going to narrow our focus down to regulatory requirements and evolving reimbursement models. We reached out to our incredible Healthcare IT Today Community to ask — how do regulatory requirements and evolving reimbursement models influence health IT strategy for payers and/or providers? The following are their answers.

Robert Connely, Global Industry Market Leader, Healthcare at Pega
The shift to value-based care is changing the role of the payer. They are no longer just the financier and gatekeeper; they are now the orchestrator. They are the entity tasked with improving the bottom line of healthcare. This means using their technology platforms and market reach to drive real improvements in medical care costs as well as administrative efficiency. It means using their powerful technology platforms to build on the interoperability and standards to connect the last mile and orchestrate the activities that create the friction today. The winning payers of the future will be those who change their relationship with providers from an adversarial to a collaborative one.

Ben Maisono, SVP Strategy at Tendo
Regulatory requirements and reimbursement shifts are among the biggest drivers of Health IT investment today. Policies like the CMS Interoperability and Prior Authorization Final Rule are pushing payers to modernize data exchange capabilities, while providers are under increasing pressure to support digital quality reporting and patient access requirements.

At the same time, evolving reimbursement models—such as bundled payments, ACO structures, and Medicare Advantage value-based arrangements—require organizations to invest in tools that support: population health management, risk adjustment accuracy, care gap closure, longitudinal outcomes tracking. Health IT strategy is no longer just about operational efficiency—it’s about enabling new models of accountability, transparency, and collaboration across the healthcare ecosystem.

David B. Snow Jr., Founder and Head of Value-Based Care at Cedar Gate Technologies, an IQVIA business
A common mistake healthcare organizations make is viewing IT as a cost center, rather than an investment in current and future performance. They piece together a patchwork of point solutions from multiple vendors to satisfy regulatory requirements for the alternative payment models (APMs) and programs they are in today, without anticipating future needs. Many organizations also try to use legacy systems built to optimize performance in a fee-for-service world in this new value-based care landscape.

We are seeing more new models coming out of CMS in recent years. The most expansive mandatory alternative payment model from CMS (Transforming Episode Accountability Model, or TEAM) is also now underway, with many industry experts predicting that mandatory and voluntary participation in APMs will only grow. That is all happening alongside ever-changing regulatory requirements from CMS.

Organizations that approach health IT systems as a strategic investment to fuel growth and success in VBC models look for systems that provide expansive data management capabilities, seamless data sharing and interoperability, advanced analytics with both predictive and prescriptive capabilities, integrated care platforms that translate insights into actionable care teams steps, and payment technology designed specifically for APMs like bundles and capitation. These capabilities span all VBC models, and are continually evolving right alongside CMS and commercial payer requirements, enabling better performance today, and well into the future—whatever it may bring.

Steve Mongelli, President at mPulse
Regulatory requirements and evolving reimbursement models are fundamentally reshaping health IT strategy for payers. With increased scrutiny around prior authorization, AI use, and data transparency, plans can’t afford to treat compliance as an afterthought. At the same time, reimbursement pressure and benefit constraints in 2026 are forcing payers to rethink everything from plan design to vendor partnerships. Digital consolidation is accelerating as plans look to drive greater ROI, strengthen security and compliance scorecards, and extract more value from fewer, more strategic partners. Health IT investments now must do double duty: ensure regulatory alignment while enabling smarter, more proactive member engagement.

There’s a significant shift toward using AI to analyze data across touchpoints and deliver the right message to the right member at the right time. However, that innovation must be balanced with oversight and governance. As reimbursement tightens and competition for member retention grows, payers must focus on leveraging interoperable, intelligent systems. Plans that use these technologies to engage members will be well-positioned to navigate the next chapter of healthcare transformation, while others risk getting left behind.

Suhas Ramachandra, VP Product Strategy & Innovation at ZeOmega
Regulatory mandates and evolving reimbursement models are forcing health IT systems to move beyond documentation toward embedded compliance and performance management. Prior authorization reform, transparency requirements, and value-based payment structures demand platforms that deliver auditability, standardized data exchange, and financial traceability by design. Today’s technology strategy is about reducing risk and proving outcomes at scale.

Marie Mitri, Director of Business Development at Navina
Medicare Advantage rate pressure and ongoing risk model revisions are reshaping Health IT priorities. The annual Advance Notice, continued V28 phase-in, and normalization adjustments are creating margin volatility that requires more precise performance management. At the same time, RADV uncertainty and heightened audit scrutiny are increasing the importance of defensible documentation practices tied to clinical evidence. As more provider organizations take on downside risk, the need for timely, traceable documentation and clearer visibility into network performance becomes more urgent. In this environment, Health IT strategy is shifting upstream, strengthening execution at the encounter, where risk capture, quality outcomes, and audit exposure are ultimately determined.

Ashley Basile, Chief Product Officer at Availity
Regulatory mandates act as both a forcing function and a strategic accelerator for health IT investment. Requirements around interoperability, prior authorization, and transparency are pushing organizations to modernize infrastructure while preparing for value-based and outcomes-driven reimbursement models. The most effective strategies treat compliance as a baseline, not the end goal, and build platforms that can adapt as policies and payment models evolve. Ultimately, organizations that align regulatory readiness with long-term data and workflow strategies are better positioned to reduce administrative burden while improving financial and clinical outcomes.

Kevin Deutsch, Chief Growth Officer at Softheon
Payers and providers are facing increased operational pressure due to changing regulatory requirements. Infrastructure that can adapt without interrupting care delivery is now critical. Health systems need to keep up with compliance requirements in enrollment, billing, and reporting while also balancing ACA changes. However, fragmented systems and integrations increase the risk of false claims or incorrect denials for patients. Health systems will need tools such as APIs and master data management to increase oversight and respond quickly to new regulatory requirements.

Rick Newell, Chief Transformation Officer at Vituity, and CEO at Inflect Health
Regulatory requirements and evolving reimbursement models don’t just influence health IT strategy; they fundamentally shape it. As payment shifts from fee-for-service to value-based and risk-bearing arrangements, technology infrastructure must support transparency, interoperability, and measurable outcomes. CMS quality programs, prior authorization reforms, interoperability mandates, and risk-based contracts all require accurate, timely, and exchangeable data. Compliance is continuous, not episodic, elevating health IT from a documentation and billing tool to a strategic asset.

For providers, reimbursement tied to quality and total cost of care demands systems that track patients longitudinally, integrate clinical and financial data, and deliver real-time performance insights. Organizations taking on financial risk need predictive analytics, population health capabilities, and standardized data governance to manage variation and improve outcomes.

For payers, increasing regulatory scrutiny and value-based contracting require digital infrastructure that enables data liquidity, automated utilization management, risk stratification, and transparent reporting.

The common denominator is adaptability. Health IT must function as a core enterprise infrastructure capable of evolving with policy and payment reform. Organizations that invest in flexible, interoperable, data-driven systems will be best positioned to navigate regulatory complexity while delivering sustainable, value-based performance.

Todd Van Meter, CEO at Accuity Healthcare
As financial pressure and regulatory oversight increase, health systems cannot afford a disconnect between the care they deliver and the way that care is documented, coded, and reimbursed. One of the next goals for health IT should be to ensure that clinical complexity is consistently translated into accurate, complete, and defensible claims at scale. Financial resilience increasingly depends on getting the documentation and reimbursement story right the first time.

Such great insights here! Huge thank you to everyone who took the time out of their day to submit a quote to us! And thank you to all of you for taking the time out of your day to read this article! We could not do this without all of your support.

How do you think regulatory requirements and evolving reimbursement models influence health IT strategy for payers and/or providers? Let us know over on social media, we’d love to hear from all of you!

As with all healthcare topics, the topic of payers and providers is very complex and multifaceted. So today, we are going to narrow our focus down to regulatory requirements and evolving reimbursement models. We reached out to our incredible Healthcare IT Today Community to ask — how do regulatory requirements and evolving reimbursement models influence health IT strategy for payers and/or providers? The following are their answers.

Robert Connely, Global Industry Market Leader, Healthcare at Pega
The shift to value-based care is changing the role of the payer. They are no longer just the financier and gatekeeper; they are now the orchestrator. They are the entity tasked with improving the bottom line of healthcare. This means using their technology platforms and market reach to drive real improvements in medical care costs as well as administrative efficiency. It means using their powerful technology platforms to build on the interoperability and standards to connect the last mile and orchestrate the activities that create the friction today. The winning payers of the future will be those who change their relationship with providers from an adversarial to a collaborative one.

Ben Maisono, SVP Strategy at Tendo
Regulatory requirements and reimbursement shifts are among the biggest drivers of Health IT investment today. Policies like the CMS Interoperability and Prior Authorization Final Rule are pushing payers to modernize data exchange capabilities, while providers are under increasing pressure to support digital quality reporting and patient access requirements.

At the same time, evolving reimbursement models—such as bundled payments, ACO structures, and Medicare Advantage value-based arrangements—require organizations to invest in tools that support: population health management, risk adjustment accuracy, care gap closure, longitudinal outcomes tracking. Health IT strategy is no longer just about operational efficiency—it’s about enabling new models of accountability, transparency, and collaboration across the healthcare ecosystem.

David B. Snow Jr., Founder and Head of Value-Based Care at Cedar Gate Technologies, an IQVIA business
A common mistake healthcare organizations make is viewing IT as a cost center, rather than an investment in current and future performance. They piece together a patchwork of point solutions from multiple vendors to satisfy regulatory requirements for the alternative payment models (APMs) and programs they are in today, without anticipating future needs. Many organizations also try to use legacy systems built to optimize performance in a fee-for-service world in this new value-based care landscape.

We are seeing more new models coming out of CMS in recent years. The most expansive mandatory alternative payment model from CMS (Transforming Episode Accountability Model, or TEAM) is also now underway, with many industry experts predicting that mandatory and voluntary participation in APMs will only grow. That is all happening alongside ever-changing regulatory requirements from CMS.

Organizations that approach health IT systems as a strategic investment to fuel growth and success in VBC models look for systems that provide expansive data management capabilities, seamless data sharing and interoperability, advanced analytics with both predictive and prescriptive capabilities, integrated care platforms that translate insights into actionable care teams steps, and payment technology designed specifically for APMs like bundles and capitation. These capabilities span all VBC models, and are continually evolving right alongside CMS and commercial payer requirements, enabling better performance today, and well into the future—whatever it may bring.

Steve Mongelli, President at mPulse
Regulatory requirements and evolving reimbursement models are fundamentally reshaping health IT strategy for payers. With increased scrutiny around prior authorization, AI use, and data transparency, plans can’t afford to treat compliance as an afterthought. At the same time, reimbursement pressure and benefit constraints in 2026 are forcing payers to rethink everything from plan design to vendor partnerships. Digital consolidation is accelerating as plans look to drive greater ROI, strengthen security and compliance scorecards, and extract more value from fewer, more strategic partners. Health IT investments now must do double duty: ensure regulatory alignment while enabling smarter, more proactive member engagement.

There’s a significant shift toward using AI to analyze data across touchpoints and deliver the right message to the right member at the right time. However, that innovation must be balanced with oversight and governance. As reimbursement tightens and competition for member retention grows, payers must focus on leveraging interoperable, intelligent systems. Plans that use these technologies to engage members will be well-positioned to navigate the next chapter of healthcare transformation, while others risk getting left behind.

Suhas Ramachandra, VP Product Strategy & Innovation at ZeOmega
Regulatory mandates and evolving reimbursement models are forcing health IT systems to move beyond documentation toward embedded compliance and performance management. Prior authorization reform, transparency requirements, and value-based payment structures demand platforms that deliver auditability, standardized data exchange, and financial traceability by design. Today’s technology strategy is about reducing risk and proving outcomes at scale.

Marie Mitri, Director of Business Development at Navina
Medicare Advantage rate pressure and ongoing risk model revisions are reshaping Health IT priorities. The annual Advance Notice, continued V28 phase-in, and normalization adjustments are creating margin volatility that requires more precise performance management. At the same time, RADV uncertainty and heightened audit scrutiny are increasing the importance of defensible documentation practices tied to clinical evidence. As more provider organizations take on downside risk, the need for timely, traceable documentation and clearer visibility into network performance becomes more urgent. In this environment, Health IT strategy is shifting upstream, strengthening execution at the encounter, where risk capture, quality outcomes, and audit exposure are ultimately determined.

Ashley Basile, Chief Product Officer at Availity
Regulatory mandates act as both a forcing function and a strategic accelerator for health IT investment. Requirements around interoperability, prior authorization, and transparency are pushing organizations to modernize infrastructure while preparing for value-based and outcomes-driven reimbursement models. The most effective strategies treat compliance as a baseline, not the end goal, and build platforms that can adapt as policies and payment models evolve. Ultimately, organizations that align regulatory readiness with long-term data and workflow strategies are better positioned to reduce administrative burden while improving financial and clinical outcomes.

Kevin Deutsch, Chief Growth Officer at Softheon
Payers and providers are facing increased operational pressure due to changing regulatory requirements. Infrastructure that can adapt without interrupting care delivery is now critical. Health systems need to keep up with compliance requirements in enrollment, billing, and reporting while also balancing ACA changes. However, fragmented systems and integrations increase the risk of false claims or incorrect denials for patients. Health systems will need tools such as APIs and master data management to increase oversight and respond quickly to new regulatory requirements.

Rick Newell, Chief Transformation Officer at Vituity, and CEO at Inflect Health
Regulatory requirements and evolving reimbursement models don’t just influence health IT strategy; they fundamentally shape it. As payment shifts from fee-for-service to value-based and risk-bearing arrangements, technology infrastructure must support transparency, interoperability, and measurable outcomes. CMS quality programs, prior authorization reforms, interoperability mandates, and risk-based contracts all require accurate, timely, and exchangeable data. Compliance is continuous, not episodic, elevating health IT from a documentation and billing tool to a strategic asset.

For providers, reimbursement tied to quality and total cost of care demands systems that track patients longitudinally, integrate clinical and financial data, and deliver real-time performance insights. Organizations taking on financial risk need predictive analytics, population health capabilities, and standardized data governance to manage variation and improve outcomes.

For payers, increasing regulatory scrutiny and value-based contracting require digital infrastructure that enables data liquidity, automated utilization management, risk stratification, and transparent reporting.

The common denominator is adaptability. Health IT must function as a core enterprise infrastructure capable of evolving with policy and payment reform. Organizations that invest in flexible, interoperable, data-driven systems will be best positioned to navigate regulatory complexity while delivering sustainable, value-based performance.

Todd Van Meter, CEO at Accuity Healthcare
As financial pressure and regulatory oversight increase, health systems cannot afford a disconnect between the care they deliver and the way that care is documented, coded, and reimbursed. One of the next goals for health IT should be to ensure that clinical complexity is consistently translated into accurate, complete, and defensible claims at scale. Financial resilience increasingly depends on getting the documentation and reimbursement story right the first time.

Such great insights here! Huge thank you to everyone who took the time out of their day to submit a quote to us! And thank you to all of you for taking the time out of your day to read this article! We could not do this without all of your support.

How do you think regulatory requirements and evolving reimbursement models influence health IT strategy for payers and/or providers? Let us know over on social media, we’d love to hear from all of you!