Impact of Upcoming Regulations on Payment Integrity: Key Considerations and Implications

Navigating the 2026 Payment Integrity Landscape: A Critical Webinar for Payers

The health insurance industry is in constant flux, shaped by evolving regulations, guidelines, and policies designed to balance consumer protection, innovation, and cost control. These shifts profoundly impact payer operations – from reimbursement models and compliance to the technologies needed for efficiency.

For payers, understanding the payment integrity implications of upcoming rules isn’t simply important; it’s essential to avoid costly errors and maintain alignment with industry standards. Proactive awareness is key to both financial stability and building trust with providers and members.

Join Cotiviti’s legal and Financial Waste & Abuse (FWA) experts on thursday, December 18th at 1 pm ET for the final installment of our 2025 Payment Integrity Pulse webinar series. We’ll delve into the critical changes coming in 2026, and what they mean for your organization.

Here’s what we’ll cover:

* The 2026 Physician Fee Schedule proposals affecting telehealth: We’ll break down how proposed CMS updates could reshape virtual care billing and impact your payer strategies.
* CMS proposals for skin substitute reimbursement and DMEPOS accreditation: Understand the potential financial and compliance ramifications of prior authorization exemptions, stricter accreditation requirements, and increased monitoring.
* Trending FWA schemes and potential challenges ahead: Gain valuable insight into emerging fraud, waste, and abuse patterns likely to arise in 2026 as a result of these rule changes.

Register Now for the Webinar

Don’t miss this crucial possibility to prepare for 2026. if you’re unable to attend the live session, register anyway to receive the on-demand recording. we look forward to your participation.

How will PSD3S stronger authentication requirements (SCA) impact current customer payment flows?

The Evolving Regulatory Landscape & Payment Compliance

The world of payment processing is undergoing a meaningful shift, driven by increasing concerns around fraud, data security, and financial crime. Several upcoming regulations are poised to dramatically impact payment integrity, forcing businesses to reassess their current practices. These aren’t just compliance hurdles; they represent opportunities to build stronger, more secure, and more trustworthy payment ecosystems. Understanding these changes is crucial for maintaining operational efficiency and avoiding costly penalties. Key areas of focus include enhanced KYC (Know Your Customer) requirements, stricter AML (Anti-Money Laundering) protocols, and evolving data privacy standards.

Key Regulations to Watch in 2025 & Beyond

Several regulations are set to reshape the payment landscape. Staying ahead of these is paramount for robust payment risk management.

* PSD3 (revised Payment Services Directive): Building on PSD2, PSD3 aims to further open up the payments market, enhance security, and promote innovation. Expect stronger authentication requirements (SCA – Strong Customer Authentication) and increased data sharing obligations. This impacts open banking initiatives and third-party payment providers.

* AML Directive 6 (AMLD6): The EU’s AMLD6 focuses on extending AML rules to the crypto-asset sector and enhancing beneficial ownership transparency. This will necessitate more rigorous transaction monitoring and due diligence for businesses dealing with cryptocurrencies.

* Digital Operational Resilience Act (DORA): Specifically targeting financial entities, DORA mandates robust ICT risk management, incident reporting, and digital operational resilience testing. This has implications for all organizations involved in the payment chain, including payment processors and service providers. Cybersecurity is a core component.

* California privacy Rights Act (CPRA) & Global Data Privacy Regulations: While not solely focused on payments, these regulations significantly impact how payment data is collected, processed, and stored. Compliance requires robust data security measures and clear data handling practices.

* The Netherlands’ NEPROM Standards (Relevance to Supply Chain Payments): While geographically specific, the NEPROM’s emphasis on financial stability and moral conduct within its membership highlights a growing trend towards ethical and responsible payment practices. This extends to supply chain finance and vendor risk management. (Source: https://zeemanvastgoed.nl/over-ons/neprom/)

Implications for businesses: A Deep Dive

These regulations aren’t abstract concepts; they have tangible implications for businesses of all sizes.

1. Increased Compliance Costs

Implementing the necessary systems and processes to comply with these regulations will require significant investment. This includes:

* Technology upgrades: Implementing advanced fraud detection systems, payment tokenization, and secure data storage solutions.

* Personnel training: Equipping staff with the knowledge and skills to identify and prevent financial crime.

* ongoing monitoring & reporting: Establishing robust systems for continuous monitoring and reporting of suspicious activity.

* Legal counsel: Seeking expert legal advice to ensure full compliance.

2. Enhanced Due Diligence & KYC Procedures

Expect more stringent requirements for verifying the identity of customers and counterparties. This includes:

* Enhanced Customer Due Diligence (EDD): For high-risk customers, expect to collect more detailed details and conduct more thorough background checks.

* Beneficial Ownership Verification: Identifying the ultimate beneficial owners of companies to prevent illicit financial flows.

* Sanctions Screening: regularly screening customers and transactions against sanctions lists.

3. Strengthened Fraud Prevention Measures

The regulations emphasize proactive fraud prevention.This means:

* Real-time Fraud Monitoring: Utilizing AI-powered fraud detection systems to identify and block fraudulent transactions in real-time.

* Behavioral Biometrics: Analyzing user behavior to detect anomalies that may indicate fraudulent activity.

* Multi-Factor Authentication (MFA): Requiring multiple forms of authentication to verify user identity.

* Chargeback Management: Implementing effective chargeback management processes to minimize losses.

4. Data Security & Privacy – A Paramount Concern

Protecting sensitive payment data is no longer optional; it’s a legal requirement.

* PCI DSS Compliance: Maintaining compliance with the Payment Card Industry Data Security standard (PCI DSS) is essential for businesses that process credit card payments.

* data Encryption: Encrypting sensitive data both in transit and at rest.

* Data Breach response Plan: Having a comprehensive plan in place to respond to data breaches.

* Data Minimization: Collecting only the data that is necessary for processing payments.

Benefits of Proactive Compliance: beyond Avoiding penalties

While compliance can be costly, proactive engagement offers significant benefits.

* Reduced Fraud Losses: Stronger security measures minimize the risk of fraud and chargebacks.

* Enhanced Customer trust: Demonstrating a commitment to security builds trust with