How Health Plans Can Stay Ahead in 2026
For health plans, this year will bring a mix of rising costs, new digital quality measures, increased audit scrutiny, and the pressure to continue embracing tech-first operations.
Where should plans focus their resources as they juggle all of these challenges?
In this INOvators episode, Mike Jones, President of Inovalon’s Payer Solutions, shares how to prepare for dQMs and rising RADV audits, tips to remain audit ready, and strategies to improve quality standards.
Plus, hear the exciting innovations Inovalon is working on this year for faster record reviews and more valuable provider-patient interactions, informed by having quality and risk gaps at the point of care.
Topics we’ll cover in the episode include:
- Predictive analytics and utilization management: How health payer solutions built on data-driven platforms can help plans spot cost spikes early and bend the cost curve
- Digital quality measures: What the shift toward real-time, streamlined quality measurement means for accuracy, efficiency, and lower admin burden.
- RADV Audit readiness and continuous compliance: Why plans need to move past a “prepare and respond” approach and toward year-round audit readiness
- Point-of-care gap closure: How new tools that integrate into electronic medical records (EMRs) can push quality and risk gaps directly into provider workflows during patient visits
- New health payer solutions for 2026: A look at Inovalon’s Converged Record Review for quality and risk, plus an expanded outreach connector ecosystem designed to close gaps in real time
Frequently Asked Questions
Find answers to the most common questions health plans are asking about digital quality measures, audit risk, and operational readiness.
1. What are the biggest healthcare payer challenges in 2026?
The biggest challenge for health plans in 2026 remains the medical cost trend. Costs are projected to rise between 8.5% and 9% year over year. Three areas are driving that growth: behavioral health services, pharmacy costs, and hospital inflation.
To manage these pressures, plans should invest in predictive analytics platforms. These tools monitor and analyze cost trends as they develop. They then feed insights into utilization management systems that help plans take action before costs spiral further. The goal is simple: use data to spot problems early and respond quickly.
Beyond cost, plans also face growing pressure from CMS on both quality reporting and risk adjustment accuracy. That means 2026 will demand sharper tools, cleaner data, and faster responses across the board.
2. How do digital quality measures help health plans improve performance?
Digital quality measures represent a meaningful shift in how plans track and report quality. These measures improve two things at once: accuracy and efficiency. They also move plans closer to real-time measurement, which means faster insight into member needs.
Here’s why that matters in practice. Traditional quality reporting often involves manual data collection. That process is slow, expensive, and prone to error. Digital quality measures cut through that burden. They let plans pull data in a more automated way, which frees up staff and lowers costs.
For plans tracking quality measures tied to CMS programs, this shift is especially important. Staying current with digital standards helps plans remain competitive and compliant. Inovalon’s Converge quality platform, for example, is designed to incorporate these digital measures and keep plans ahead of the curve heading into 2026.
3. How can health plans reduce CMS audit penalties and stay RADV Audit ready?
CMS has increased its scrutiny around Risk Adjustment Data Validation. For health plans, that means the old way of doing things is no longer enough. Plans that only prepare when an audit is announced are falling behind.
The smarter approach is continuous compliance. Instead of reacting to audits after the fact, leading plans are building audit readiness into their daily operations. Three strategies stand out:
- Increase provider outreach to improve documentation quality at the point of care. When providers capture conditions accurately during a visit, there’s less risk of errors downstream.
- Implement strong data quality standards across every stage of the risk adjustment process. Clean data in means cleaner results out.
- Maintain proactive audit compliance readiness year-round, not just during audit windows.
Looking Ahead
The 2026 payer landscape demands more than incremental improvements. Health plans need better data, faster insights, and tighter alignment between quality, risk, and compliance workflows.
The good news: the tools and strategies already exist today. From predictive analytics that flag cost trends early to digital quality measures that cut admin burden and point-of-care integrations that close gaps in real time — plans that invest in these capabilities now will be the ones best positioned to manage costs, meet CMS expectations, and deliver better outcomes for their members.
