January 2026: The 2026 Payor Outlook
Insights, Trends, and Strategy
Thank you to everyone who joined us for our first ROC Masterminds discussion of 2026. This session, led by Hansei Solutions, focused on reflecting on the changes and challenges providers faced with payors in 2025—and what those trends suggest for the year ahead.
If you missed the session, you can view the full recording here:
View Recording: https://hanseisolutions.zoom.us/rec/share/k1-T1raQT5RtHl6-HUjvHDTweeduehFYa69E-Jj0v7LeDOA4-rSFDybNurModIn8.nC9OPPYC73Z_Pli-
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Below is a recap of the key takeaways and strategic insights discussed.
Looking Back: Key Payor Trends from 2025
Across multiple states, providers noted that unusually favorable payor behavior often preceded later challenges. This sentiment was echoed nationally, particularly in conversations around fee schedules and claim handling. Hansei also reported a noticeable uptick in audits throughout 2025, adding to the already heavy administrative burden providers faced—an issue expected to remain a key discussion point in 2026.
Claim Denials and Administrative Disruptions
Colorado providers reported widespread claim denials where replacement claims were deleted, new information was inserted, and original claim data was removed—even when referencing the original claim number. This may be tied to HCPCS/HIPPS coding issues, though clarity remains limited.
Similar concerns were raised in Texas and Virginia, highlighting the lack of consistency across states.
Payor-Specific Insights
While many challenges in 2025 were felt across the industry, certain payors stood out due to recurring patterns, enforcement shifts, and increased administrative strain. Below is a closer look at the payor-specific trends discussed, highlighting where providers experienced the greatest disruption and what may carry into 2026.
Ambetter
Providers across the Southeast—including SC, NC, TN, TX, AR, MS, FL, KY, and GA—reported significant challenges.
2025 proved especially difficult due to:
Historically confusing contracts
Changes in rates and service language
Inconsistent enforcement of policies
While Ambetter appears to be moving toward consolidation and standardization, execution remains inconsistent from state to state.
Provider manuals are being enforced more strictly, yet authorization backlogs, inconsistencies, and turnaround delays—especially for lower levels of care—persist.
Aetna
Audit flags emerged in 2025, a notable shift from prior years, as many providers had not encountered Aetna audits before 2024/2025.
Audits are impacting both in-network and out-of-network providers.
There is concern that actions by a small number of “bad actors,” particularly in California but also nationwide, may be driving these broader enforcement trends.
The result: a significant administrative burden for compliant providers.
Cigna
Retrospective reviews were a major pain point, with attendees noting that no one present had successfully passed one to date.
There is growing concern that behavioral health providers are being disproportionately targeted.
Hansei encouraged providers to share insights and data to help identify patterns and support potential parity complaints, as these practices may represent systemic exploitation of providers.
Looking Ahead: What 2026 Is Likely to Bring
Affordable Care Act (ACA) Implications
ACA plans are trending toward narrower networks across all states.
As premium payment structures evolve, providers should prepare for increased scrutiny and tighter contracting.
Case Rates and Contracting Strategy
Payors are increasingly interested in case rates, but they need clarity from providers.
The takeaway: you must clearly define and communicate what you do.
Communication cannot be overstated—it is not possible to overcommunicate.
Defining Quality and Outcomes
Payors are looking to providers to lead the conversation on quality:
Show your outcomes.
Define what success looks like for your patient population.
Recognize that adult and adolescent outcomes differ, and your benchmarks should reflect that.
Consider broader quality-of-life indicators:
Living stability
Employment
Medical engagement
Reduced ER visits
Overall patient well-being and satisfaction
Providers know their patients best—and payors have acknowledged that they rely on providers to build, study, and define their own outcome measures.
Full Continuum of Care Matters
Outcomes should reflect pre-treatment and post-treatment trajectories, not just a single episode of care.
Establish internal benchmarks and track progress over time.
Research partners, such as Vista Research Group, were mentioned as valuable resources in this area.
Staying Connected and Moving Forward
ROC’s objective remains the same: we are a team. If you need support, insight, or want to share updates on how payors are impacting your organization, please reach out: ROC@hanseisolutions.com.
We also want to hear from you—what topics would you like ROC Masterminds to cover in 2026?
👉 Submit your ideas here: https://form.jotform.com/230033849608154
And don’t forget—join us for the upcoming ATAC Event in Long Beach, CA, on Tuesday, January 20th. Learn more: https://events.atac.org/
Finally, stay tuned for more updates soon. February will bring early indicators of how these changes are materializing, so stay tuned. We’ll see you next month!