From regulatory uncertainty to technological disruption, health plan leaders face mounting pressure to adapt. For insights on what organizations must do to thrive in 2026, RISE turned to industry experts Branka Sustic, vice president of risk and quality solutions, Cotiviti, and Dr. Summerpal Kahlon, chief medical officer, Edifecs, a Cotiviti business.
Sustic (pictured above left) and Dr. Kahlon (pictured above right) recently joined RISE Radio to discuss risk adjustment strategies for the year ahead while navigating unpredictable regulations, persistent cost pressure, rising utilization, and a deluge of data. But the conversation continued long after the recording stopped.
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Here’s a summary of their thoughts on the challenges plans faced this year as well as the biggest pitfalls health plans should avoid and the opportunities to embrace in 2026.
The 2025 backdrop: Pressure from all sides
Both Sustic and Dr. Kahlon noted the challenging operating environment organizations faced this year:
Compliance focus: Ongoing scrutiny of Medicare Advantage, such as Risk Adjustment Data Validation (RADV) audit expansion and proposed measures to curb upcoding and reduce overpayments, kept plans cautious and focused on compliance.
Economics under strain: Health plans balanced offering competitive benefits with tightening margins; providers faced cost and capacity constraints; and patients returned to engage with the health care system again after post-COVID lows.
Coverage changes: Shifts in enrollment and eligibility requirements in the Affordable Care Act (ACA) and Medicaid markets are impacting enrollment forecasts and risk pools.
4 costly mistakes health plans can’t afford to make in 2026
In the year ahead, Sustic and Dr. Kahlon said organizations should avoid these common traps:
Doing nothing: The biggest mistake organizations can make is failing to try new approaches or identifying a problem but maintaining the status quo and not doing anything to fix it, Sustic said. Be open-minded and try new things: even with small, scalable investments and proven techniques, you can discover new approaches and drive improvements. Once organizations select their priorities, they can better decide and adapt their plans to achieve their goals. Leaders should prioritize modernization by aligning their efforts with well-defined objectives, budgets, and resources.
Building tech without a use case: No pilot should proceed without defined KPIs and compliance criteria, they said. Start small before attempting to scale the project. The bigger the project, the more complex it is. Before you begin, consider your end goal and know the metrics you want to hit, Dr. Kahlon said.
Ignoring providers’ experience: Redundant requests and siloed programs erode engagement. Learn what providers want or don’t want to engage with to create a holistic experience.
Struggling with fragmented, late, or inaccessible data: As data volumes grow, organizations still struggle to find, normalize, and deliver the right information in time to matter. “Plans are drowning in data,” Dr. Kahlon said. “The question is: how do you unlock it and make it actionable?”
4 strategies to turn disruption into advantages
Despite rapid change within the industry and regulatory unpredictability, opportunities exist and there is room for growth, said Sustic and Dr. Kahlon. Indeed, organizations that embrace technology and operational discipline can turn these challenges into competitive advantages.
Treat data as critical infrastructure: Managing increasing amounts of data is a growing issue. Access to organized data is a priority for all health plans, they said. Consolidate, digitize, and govern data across risk and quality to support audits, analytics, and point‑of‑care engagement.
Blend mature AI with human judgment: Both Sustic and Dr. Kahlon favor mature, vetted artificial intelligence embedded in everyday workflows over unproven tools. They suggest using AI for scale, speed, and workflow efficiency, while preserving expert coder review to ensure quality and compliance. “AI enables efficiency, but the human touch will never go away. Coding is an art, not just a science,” Sustic said.
Implement “a shift to the left” in your operations: Move insight and intervention earlier in the member journey to improve documentation, enable timely clinical programs, and reduce avoidable costs. The goal isn’t just more accurate capture; it’s earlier care activation that can improve outcomes and total cost of care. “Why wait until the end of the year to find out how complex your patients are?” Dr. Kahlon asked. “Learn earlier so you can make a positive impact.”
Integrate risk and quality: Provider abrasion is a growing concern, but integration of risk and quality programs can ease the burden and unlock efficiency gains. Separate risk and quality programs often operate in silos, each requesting the same records for different purposes. By reusing medical records and implementing complementary workflows, health plans can drive efficiency gains while easing the burden on provider practices.
2026 is around the corner—Don’t wait too long to make changes
As health plans prepare for 2026, the message is clear: regulatory uncertainty, economic pressures, and data complexity aren’t going away. But organizations that embrace modernization, integrate risk and quality, and treat data as a strategic asset can turn these challenges into opportunities. By blending proven technology with human expertise, shifting interventions earlier in the member journey, and prioritizing provider collaboration, health plans can not only avoid costly missteps but also position themselves for sustainable growth and better outcomes in the swiftly evolving health care landscape.
About the subject matter experts
Branka Sustic, vice president of risk and quality solutions, Cotiviti, provides leadership and oversight into product and business development, client program management, and strategy to assist health plans in meeting their quality and risk adjustment goals, optimization of revenue, and risk mitigation. She is a leader with more than two decades of health care experience, blending a strong customer service and analytic foundation with experience leading change management throughout her career. Sustic is known for creating and establishing operational and support plans leading to increased client satisfaction and performance.
Dr. Summerpal Kahlon, chief medical officer at Edifecs, a Cotiviti business, works across products and functions to guide clinical strategies and policies. His career spans over 20 years of experience in diverse health care settings, businesses, and markets. Dr. Kahlon has deep expertise in value-based care and risk adjustment and brings unique insight to help customers make the most comprehensive, informed, and clinically relevant decisions for their populations.
About Cotiviti
Cotiviti enables healthcare organizations to deliver better care at lower cost through advanced technology and data analytics that improve the quality and sustainability of healthcare in the United States. Cotiviti’s solutions increase transparency and collaboration between payers and providers while empowering them to reduce medical and administrative costs, enable better health, improve claims payment efficiency, streamline operations, drive interoperability, and advance value-based care. Its customers serve the majority of U.S. healthcare consumers, providing coverage and care for over 300 million members and patients.