Three forces — artificial intelligence, faster care pathways, and research-based insights— could help claims organizations navigate a care management landscape where claim frequency is declining but severity and financial exposure continue to rise, according to MedRisk’s 2026 trends report.

Claim complexity is intensifying as the workforce ages, comorbidities increase, and low-severity cases become a smaller share of the mix, leaving organizations managing claims with greater financial risk and longer resolution timelines, MedRisk said. According to the report, days from injury to initial conservative treatment for lumbar spine conditions dropped 50% between 2021 and 2025, signaling broader system improvements that extend across multiple injury types.

AI Moves From Pilot Projects to Operational Reality

AI has largely exited the experimentation phase, but a significant gap remains between pilot programs and scaled production, MedRisk said. Most organizations have moved past debating whether to adopt AI and are now grappling with how to implement it responsibly and effectively, according to the report.

The challenge is that pilot projects do not automatically translate into reduced cycle times, better recovery outcomes, or lower total costs, MedRisk said. Many programs stall when organizations underestimate the upfront work required: cleaning data, establishing governance, and redesigning workflows to actually reduce friction rather than create it.

Organizations that are seeing durable results treat AI as an operating model change rather than a simple technology addition. MedRisk’s analysis suggests that success requires longitudinal, governed data; clear controls on how AI is applied; maintained human decision-making authority; and transparent, auditable systems designed for regulated healthcare environments.

When these foundations are in place, AI can compress cycle times and reduce unnecessary spending without introducing new risks, the report said.

Treatment Pipelines Are Becoming More Efficient

Across bill review and physical therapy data, a clear pattern has emerged: despite growing claim complexity, patients are entering treatment sooner across multiple injury categories, MedRisk said. This improvement in the pipeline to care reflects enhanced documentation, better referral coordination, more efficient peer review processes, and streamlined claims processing rather than changes in clinical behavior alone.

Faster access to conservative care, particularly physical therapy, represents one of the most significant developments. Historically, delays in initiating therapy have been linked to prolonged disability, higher pharmaceutical reliance, and increased advanced interventions, the report noted. By moving patients into appropriate conservative treatment earlier, organizations are supporting better functional recovery and more stable downstream outcomes.

The pattern also appears in advanced imaging, MedRisk said. Patients meeting clinical thresholds for MRI or CT imaging are completing these studies more rapidly and earlier in their treatment course, helping set patients on more timely recovery trajectories. Importantly, this reflects improved workflow and clearer clinical decision-making rather than indiscriminate ordering or loosened clinical criteria.

The industry continues to balance two critical priorities: reducing unnecessary delays and maintaining disciplined, evidence-based utilization management. The current data suggests this balance is improving, the report said.

Specific Leverage Points for Better Outcomes

Recent research reinforces that early insight, appropriate utilization, and thoughtful intervention meaningfully influence recovery and total claim trajectories, according to MedRisk. Several findings have direct implications for claims management strategies.

Wide variation in surgical decision-making among providers treating similar conditions creates corresponding variation in claim outcomes, the report said. Among spine surgeons, for example, instrumented fusion rates for comparable lumbar conditions ranged from nearly zero to over 90%, with meaningful differences in complication rates and readmissions.

Surgeon selection and referral strategy therefore directly affect recovery time, complication risk, and total spend, MedRisk said.

Imaging interpretation also carries significant implications. Research shows that abnormalities in rotator cuff imaging are nearly universal among adults, appearing in 96% of asymptomatic shoulders and 98% of symptomatic shoulders, MedRisk said. When structural imaging findings are treated as the cause of pain without clinical context, care can escalate unnecessarily.

Another critical finding addresses pharmaceutical management. Workers using opioids before spinal surgery had approximately half the odds of achieving stable return to work compared to non-users — a substantial signal for early pharmacy oversight and behavioral risk management, the report said. Cutting return-to-work odds in half represents a meaningful leverage point for intervention, MedRisk said.

View the trends report here. &