Top Compliance Priorities for U.S. Healthcare Payer Organizations in 2026 Delivering strategic insights and guidance for health plan compliance leaders Leyla Erkan, Managing Director, Global Healthcare Legal, Risk & Compliance Practice Leader and Megan Allison, Associate Director, Global Healthcare Legal, Risk & Compliance Payer Practice Leader 3 min read Protiviti’s legal, risk and compliance experts weigh in on the most critical compliance risks and priorities facing U.S. healthcare payer organizations in 2026, underscoring the need for strategic oversight amid regulatory uncertainty, financial pressures and rapid technological change. To remain resilient, trustworthy and legally sound in an increasingly complex healthcare landscape, organizations must embrace proactive governance, continuous monitoring and cross-functional collaboration. With regulations shifting fast, healthcare organizations need compliance programs that are robust, adaptive, and effective. Overview of Payer Compliance Priorities**Priorities are not listed in order of importance + EXPAND ALL Compliance Program Effectiveness + Health plans that continuously test, evidence and improve compliance programs are best positioned to protect members, maintain trust and avoid costly disruptions. Vendor and Delegated Entity Oversight + Vendor oversight must be treated as a core compliance function to meet regulatory obligations, strengthen program integrity and maintain operational resilience. Privacy and Security + Proactive privacy and security strategies are essential for health plans to safeguard health data while enabling innovation, compliance and trust. One Big Beautiful Bill Act (OBBBA) + OBBBA and other rapidly changing federal and state laws (e.g., HIPAA updates, Medicare Advantage RADV rules) demand early preparation, robust monitoring and transparent leadership to navigate OBBBA’s challenges, safeguard organizational integrity and avoid enforcement risks. Fraud, Waste and Abuse (FWA) + Robust FWA oversight, powered by targeted controls and collaboration, can help safeguard organizational revenue, protect members and ensure alignment with federal expectations. Impacts of Artificial Intelligence + Robust AI governance frameworks are essential to harness the power of AI while upholding member trust and regulatory integrity. Prior Authorizations, Appeals and Grievances + Strong utilization management (UM) governance ensures members receive timely access to medically appropriate care while enhancing the ability to meet regulatory expectations, reduce avoidable delays and strengthen member trust and outcomes. Provider Directories + Precise provider directory management is a strategic and regulatory imperative that safeguards compliance, reputation and member access to care. Risk Adjustment + Accuracy in risk-adjustment coding, backed by strong governance and accountability, can help organizations navigate risk-adjusted payment models, reduce enforcement actions under the FCA, and protect organizations from legal exposure and reputational harm. Pharmacy Benefit Manager (PBM) Oversight + Effective oversight of PBMs helps ensure compliance with regulatory requirements, promotes transparency in drug pricing, and preserves member interests. Strong monitoring practices help mitigate financial and operational risks while reinforcing program integrity and trust. Encounter Management + Strong compliance frameworks around encounter data mitigate risk and ensure accurate reimbursement while reinforcing the health plan’s commitment to high-quality care. These risks are interconnected and require proactive, strategic compliance leadership to mitigate regulatory, financial and operational threats in the evolving healthcare environment.Read full report Topics Risk Management and Regulatory Compliance Industries Healthcare Leadership Leyla Erkan Leyla is Protiviti’s Global Healthcare Compliance Practice Leader. She brings over 25 years of experience in compliance and risk management, including a distinguished career as a Chief Compliance, Privacy and Research Officer. Leyla has deep expertise in regulatory ... Learn More
