How do we scale high-impact clinical integrity programs using smart targeting to reduce review volume while increasing savings? 

While traditional payment integrity concepts continue to deliver more savings, AI and advanced technologies are enabling new PI concepts. How are health plans identifying the “next big thing” in payment integrity? This panel will explore how leading organizations are scaling new savings concepts, the role of AI in accelerating discovery and prioritization, and what will differentiate top-performing payment integrity programs in the year ahead.
- How new PI concepts are identified, vetted, piloted, and scaled
- How to prioritize the right opportunities without overwhelming PI teams or creating provider abrasion
- New tech-enabled billing (e.g., digital therapeutics, remote monitoring, AI-assisted services) and unlisted codes

Payment integrity is evolving from a downstream claims audit function to a proactive, critical lever for upstream cost avoidance. Payment integrity leaders note that ‘shifting left’ can cut administrative duties by at least 10-15%, in addition to improving provider abrasion. But evolving to cost avoidance not only requires a shift in mindset, but an evolution in how data, AI tools, and cross-functional collaboration are used to enable proactive decision making.

- Case studies: Critical strategies for launching pre-pay programs and measuring ROI
- How AI is expanding pre-pay capabilities and required governance
- Rethinking the impact and attribution of provider education initiatives

The payment integrity vendor landscape has expanded rapidly, with plans now juggling specialist partners across pre-pay, post-pay, DRG validation, COB, FWA, clinical review, and an ever-growing list of AI-enabled point solutions. While each vendor promises incremental savings, the cumulative cost of sourcing, contracting, onboarding, integrating, and reconciling reporting across a sprawling stack is becoming a payment integrity problem in its own right. This panel brings together PI leaders who have wrestled with rationalising their vendor ecosystems to share practical approaches for building a leaner, better-orchestrated, and easier-to-manage vendor stack without losing savings yield.
- How to evaluate and source new vendors efficiently, including which proof points and pilot structures actually predict in-production performance
- Designing a waterfall and integration model that minimises duplicate findings, claim leakage, and operational drag across multiple vendors
- Consolidating vendor reporting and KPIs into a single view so PI leaders can defend total program value to senior leadership

Code updates. Site-of-service rule changes. Specialty drug billing classifications. Telehealth policy still being written. Coding technology evolving. The environment that edit programs have to keep up with in 2026 is more complex than it has ever been, and an annual review cycle is not enough. This session looks at what a well-governed, modern, continuously maintained edit program looks like in practice, where the most costly gaps tend to open and how technology can keep your plan ahead. 

- How to build an edit governance process that keeps pace with frequent policy changes across multiple lines of business
- Where the highest-risk edit gaps are opening right now and how to prioritise closing them without expanding every programme at once
- How to defend edits in provider disputes when the underlying policy they are based on is itself in transition

Key discussion points:
- How state agencies and managed care organisations can build collaborative infrastructure to facilitate information exchange among MCO SIUs, oversight bodies, actuaries, and auditors
- Impact of shared information exchange on anomaly detection, high risk providers, and overpayment management
- How improved collaboration impacted managed care rate setting