The Influence of Regulatory Changes and Evolving Payer Requirements on RCM Technology Strategy and System Selection

Life is ever-changing and complex. This means that the regulations and requirements we’ve made previously cannot be permanent. They need to be updated regularly to match the current state of our lives and the world. However, these changes don’t happen in isolation. Regulatory changes often become an oreborus – where the world changes, causing regulations to change, which in turn changes how we operate, which can cause more changes in regulations, and the cycle continues.

For a more in-depth understanding of how regulation and requirement changes influence our behaviors in healthcare, we reached out to our wonderful Healthcare IT Today Community to ask — how do regulatory changes and evolving payer requirements influence revenue cycle management technology strategy and system selection? What regulatory changes would you like to see changed?

Thomas Shea, Chief Revenue Officer, AI and Patient Affordability Solutions at Doceree
Regulatory shifts — the No Surprises Act, price transparency mandates, prior authorization reforms — don’t just change compliance checklists, they reshape technology strategy entirely. Systems need to be agile and reconfigurable, not rigid. From my experience building patient affordability solutions that operate inside clinical workflows, I’ve seen how proactively surfacing cost information at the point of prescribing — before care is delivered — directly addresses the intent behind price transparency legislation.

The regulatory change I’d most advocate for is standardizing prior authorization timelines across payers. Today’s fragmented, payer-by-payer approach wastes enormous clinical resources and delays patient care. Standardization benefits everyone — and frankly, it’s long overdue.

Anand Biradar, SVP of Enterprise Transformation at Sagility
Regulatory changes and evolving payer requirements are fundamentally reshaping RCM technology strategy. Organizations must continuously adapt to new reimbursement models, documentation standards, and compliance expectations, which makes flexibility and configurability in platforms critical. At the same time, the industry would benefit from greater standardization across payer policies and prior authorization requirements to reduce administrative burden, improve transparency, and allow providers to focus more on care delivery rather than navigating complexity.

Scott Schrader, President, Provider Healthcare Solutions at Firstsource
Payers now update clinical coverage policies weekly, and CMS rule changes and IPPS revisions land continuously. Static monolithic platforms were not designed to absorb this pace — making technology agility, not just capability, the defining selection criterion for revenue cycle systems. This is driving health systems toward modular, composable architectures where individual components can be upgraded or replaced independently as better capabilities emerge, without disrupting the broader operation.

Organizations are also recognizing the hidden cost of technology lock-in: a two- or three-year contract with an AI vendor that locks in that vendor’s capabilities at a single point in time, in a field where what was best-in-class at signing may be a generation behind by year two. The organizations navigating this best are choosing platform partners that maintain technology agility on their behalf, delivering continuous access to best-available capabilities without the 6-to-18-month RFP and implementation cycle that each new point solution would otherwise require.

Monte Sandler, Chief Operating Officer at WebPT
RCM is shaped by constant change. Every payer has different rules, and those rules are constantly changing. That is why technology needs to be flexible and driven by data, not hardcoded logic. Systems have to adapt in real time, or they fall behind. More standardization across payers would remove a lot of unnecessary complexity and make the entire system work better.

Yusuf Qasim, President, Payments Optimization at Zelis
Regulatory change and evolving payer requirements shape RCM technology strategy because they add constant complexity to payments, communications, compliance, and workflows. But the issue is not simply a lack of standards. Healthcare has already standardized many administrative transactions; the harder problem is that adoption of those standards remains uneven or flat. Recent CAQH data supports this, with several electronic transactions showing limited movement from 2023 to 2025 and electronic claim payment adoption still below full adoption.

That means flexibility, interoperability, and scalability have to be top priorities when selecting an RCM system. Organizations need platforms that can adapt to changing rules and payer requirements without creating more point solutions, workarounds, or administrative burden. The best technology should simplify operations while improving payment speed, accuracy, and experience.

If I could change one thing, it would be to shift regulation away from adding more prescriptive requirements and toward improving adoption of the standards that already exist. Some rules do not fully account for established standards, while others focus too much on mandating a process instead of simplifying the problem they are meant to solve. Better policy would align around outcomes, reduce fragmentation, and give organizations more flexibility in how technology achieves the intended result.

Ben Maisono, SVP, Head of Strategy at Tendo
Regulatory tailwinds are here for providers and patients regarding Prior Authorizations, which by January 1 2027, payors must implement standard FHIR API interoperability, public records of stats on denials, and timely responses with reasons for denials. These requirements, driven by CMS, are promising to streamline one of the most cumbersome and opaque areas of RCM. This is the foundational work to now let the AI agents take it over.

Rigid systems that rely on static rules will struggle to keep up with changing authorization requirements, billing guidelines, and automation expectations. As a result, many organizations are prioritizing platforms that can ingest new rules quickly, apply them consistently across workflows, and surface changes proactively to staff.

From a broader perspective, the No Surprises Act and other price transparency requirements for payers and providers are now resulting in a more informed ecosystem where natural market dynamics will start to take effect. It’s time for providers to use transparency not as a burdensome requirement to meet, but as an advantage to make healthcare shoppable as a competitive advantage. Employers are looking to do direct contract contracting, CMS and commercial payers are evolving models to pay for outcomes, including reimbursement for the technology to achieve it. The RCM space is about to have to adopt new models like CMS Access, evolving quality programs like CMS Stars that will require clinical data for risk adjustment, and other new models of healthcare commerce.

Tavi Schlueter, Growth Initiatives Director at CollabDocs
Regulatory changes and evolving payer requirements have made revenue cycle management one of the most complex parts of running a nurse practitioner-led practice. The biggest challenge is that rules around practice authority, credentialing, and billing still vary widely by state, which creates friction for providers trying to expand care across multiple markets.

The inconsistency means organizations want RCM technology that can adapt quickly — systems need to account for different payer rules, track credentialing across states, and catch issues before they turn into denied claims. Without that flexibility, even small compliance gaps can delay reimbursement and disrupt operations. I’d like to see a move toward more standardization across the board. Multi-state adherence to elements like credentialing requirements and payer expectations would reduce administrative work and make it easier for providers to deliver quality care. Until then, building effective strategies depends on technology that can handle complexity behind the scenes so clinicians aren’t the ones carrying it every day.

Sunil Konda, Chief Product Officer at SYNERGEN Health
Things like the No Surprises Act, CMS’s price transparency rules, and prior authorization mandates have forced RCM platforms and solutions to become more adaptable, and this is why you see regulatory flexibility as a first-order criterion to prevent major re-engineering efforts every time there are significant rule updates.

As for what I’d like to see changed, prior authorization remains one of the most wasteful and clinically disruptive areas in healthcare. CMS has made progress with its interoperability and prior authorization final rule, but enforcement timelines lag, and the requirements don’t apply uniformly across all payers. I’d advocate for a universal, standardized electronic prior authorization requirement with real accountability, defined response times, standardized criteria, and meaningful penalties for noncompliance. That single change would reduce administrative burden, accelerate patient access to care, and free up billions in operational costs across the system.

Amy Houlihan, Managing Director, Performance Improvement – Advisory Services at Nordic
Regulatory change isn’t slowing down, so RCM technology needs to be built to adapt, not just react. The challenge is that regulatory and payer changes are constant and often disconnected from how systems are set up. Requirements around prior authorization, interoperability, and value-based care are pushing organizations to rethink whether their current tools can actually keep up. We’re seeing more focus on flexibility—systems that can adapt to changing rules, support better data sharing, and reduce manual workarounds.

At the same time, there’s growing pressure to align clinical, financial, and compliance workflows. For example, prior auth and quality reporting aren’t just regulatory tasks. They directly impact reimbursement and cash flow when they break down. Organizations doing this well are taking a more proactive approach, treating regulatory readiness as part of their overall technology and operations strategy, not just a compliance exercise.