Rising medical costs, more complex claims and shifting clinical practices made 2025 a demanding year for both payers and providers. Payers faced pressure on medical loss ratios and administrative costs, while providers navigated higher denial rates, more audits and tighter reimbursement cycles. As claim complexity grows, payment integrity is no longer a back-office function — it’s a shared path to financial resilience across the ecosystem.
At Zelis, we analyzed 20 months of Payment Integrity performance data (January 2024–August 2025) and paired it with leading industry research to understand how cost, complexity and accuracy are shifting — and what payers need to be ready for in 2026.
Here’s what we found.
Trends that Shaped 2025
Trend #1: Denial activity is rising — both in volume and financial impact
- FinThrive’s 2025 analysis found denial rates now affecting more than 10% of claims, with denial-related write-offs tripling since 2018.
- MDaudit’s 2025 Benchmark reported denied dollars up 12% for outpatient and 14% for inpatient, plus a 30% increase in external payer audit at-risk dollars.
- HFMA’s 2025 Denials Roundtable highlighted a 126% rise in coding-related denials over three years, signaling growing operational strain for revenue cycle teams.
Denials play a critical role in preventing inappropriate payments, but the downstream impact is real: provider abrasion, rework and longer reimbursement cycles. As denial activity grows, the need for more precise, proactive Payment Integrity becomes even clearer.
Trend #2: Coding accuracy is now a major source of financial exposure
- Coding and documentation issues emerged as leading drivers of avoidable spend in 2025:
- Roughly one in four denials were tied to coding inaccuracies.
- Outpatient coding denials increased 26%in 2025, following a triple-digit surge the year prior.
- Medicare Advantage medical-necessity and documentation denials also rose significantly.
As clinical practices evolve and documentation demands expand, accurate coding has become more than a compliance requirement — it’s a margin imperative for both payers and providers.
Trend #3: Rising medication costs reshaped payer spend
Medication expense continued to accelerate in 2025, creating new financial pressure for payers:
- U.S. prices for new drugs more than doubled between 2021 and 2025.
- While 2025 increases were moderated by the Inflation Reduction Act, drug price growth still outpaced overall inflation.
- Patent term extensions and other patent strategies continued to delay generic competition, sustaining higher prices.
These shifts underscore how fast pharmaceutical innovation can introduce new coding, policy and documentation requirements — and how quickly discrepancies and claim errors can follow without strong Payment Integrity controls.
Trend#4: Advanced therapies raised the stakes
CMS’s 2026 Physician Fee Schedule introduced bundled payment for CAR-T and autologous cell/gene therapies, consolidating multiple preparatory steps into a single payment structure.
For payers, incorrect unbundling can lead to significant overpayments on therapies priced in the six-figure range. For providers, inconsistent bundling rules pose real revenue risk.
As high-cost therapies expand, both sides need clinically grounded Payment Integrity to ensure accurate reimbursement and reduce financial exposure.
Trend#5: AI and automation became core to the workflow
Technology adoption accelerated across payer and provider operations in 2025:
- AI-enabled coding solutions reached 95%+ accuracy in code prediction.
- Automation benchmarks showed labor cost per claim down ~35% and denial rates down 30–40% in leading deployments.
- Gartner’s 2025 Hype Cycle highlighted Intelligent Prior Authorization and AI-driven fraud detection as transformational capabilities for payers.
AI is no longer an experiment. It’s becoming foundational to Payment Integrity — improving accuracy, reducing manual work and strengthening confidence across complex claim workflows.
What Zelis Saw: Where Cost and Risk Actually Shifted
Across 20 months of Zelis Payment Integrity data, several patterns reinforced what the broader market is experiencing.
Observation #1: High-cost categories accelerated fastest
Allowed dollars did not rise evenly across services. The steepest increases were concentrated in high-intensity categories where clinical and coding complexity are also expanding.
Observation #2: Allowed dollars grew sharply across key service lines:
- Medicine/Pharmacy/Vaccine: +44%
- Radiology: +26%
- Emergency Department: +19%
- Pathology/Lab: +14%
- Behavioral Health: +13%
- Anesthesia: +17%
- Physical Therapy: +12%
Across all services, the average allowed dollars per claim increased by 16%.
For payers, the implication is clear: cost growth is concentrated in categories with significant coding variability — amplifying both payment risk and operational burden.
Observation #3: Coding complexity amplified payment risk
Zelis audit teams identified recurring issues in the highest-cost categories:
- Imaging claims with multiple-procedure reductions were not properly applied prior to Zelis review.
- Dermatology procedures with inconsistent coding for skin substitutes and tissue transfers.
- Obstetrics and neonatal claims with inaccurate global package calculations prior to review.
- Laboratory testing submissions with duplicate or non-covered services.
This pattern — high-cost categories paired with high coding variability — underscores why precise, clinically aligned Payment Integrity is essential for minimizing leakage.
Observation #4: Targeted edits delivered more value than broad controls
In 2025, Zelis deployed 156 new edits across dermatology, ambulance services, lab testing, obstetrics and neonatal care. These edits were designed not to increase denials, but to:
- Concentratepayer oversight where dollars areactuallyshifting
- Reduce unnecessary friction through greater specificity
- Provide clean, actionable rationale back to providers.
The result: more accurate savings, fewer false positives and stronger alignment with provider workflows, reinforcing that targeted, clinically grounded edits outperform broad, generic controls.
How Zelis Is Helping Payers Prepare for 2026
Payers are entering 2026 with two parallel imperatives: protect financial performance and maintain collaborative provider relationships. Zelis is supporting that balance through four strategic focus areas.
1.Prioritizing the fastest-growing cost categories
We’re aligning our roadmap to high-growth segments like pharmacy, radiology, ED, anesthesia, PT and behavioral health. These categories sit at the intersection of coding complexity, documentation variability and policy change, making proactive oversight essential.
2. Bringing clinical context into every edit
Our clinical, coding and data science teams continue to enhance edits to reflect real-world clinical scenarios, including:
- Drug-to-diagnosis validation for high-cost medications.
- Appropriate documentation.
- Bundle-aware edits for advanced therapies.
The goal: help payers prevent inappropriate payments without overcorrecting or creating unnecessary abrasion.
3. Complementing payer AI and automation — not competing with it
Zelis integrates directly with payer analytics environments to strengthen existing investments, not replace them. This includes:
- Proactively identifying and routing claims for Payment Integrity risk pre-payment
- Continuously tuning edit logic based on payer-specific patterns and outcomes
- Delivering clear, actionable messaging that reduces provider back-and-forth.
We see AI not as a replacement for rules, but as a force multiplier that sharpens precision and reduces manual work.
4. Grounding our roadmap in real Zelis claims intelligence
Every enhancement is driven by insights from the data we see every day — ensuring our roadmap reflects:
- Actual cost movement
- Actual provider behavior
- Actual emerging risk
Not theoretical assumptions or generic market models.
A More Collaborative Model for Payment Integrity
If 2025 proved anything, it’s that Payment Integrity is no longer a back-office safeguard; it’s a strategic lever for payer performance and network stability.
High-cost drugs and advanced therapies will continue to reshape benefits. AI and automation will accelerate across payer and provider workflows. And clearer, more transparent edits and payment rules will be essential for reducing abrasion and strengthening trust.
As you plan for 2026, we’d welcome a conversation about how these trends are emerging in your book of business — and how Zelis can help you stay ahead of what’s next.
