China’s prompt settlement reform for basic medical insurance funds follows three main pathways: “optimizing traditional settlement methods by shortening the monthly settlement period,” “promoting payment upon individual claims to increase the frequency of fund disbursement,” and “implementing monthly prepayment with claim-by-claim accounting.” Using thematic framework analysis of interview and survey materials from Province A, this study applies the Technology–Organization–Environment (TOE) framework to compare pathway characteristics and examine adaptation problems and underlying mechanisms. The findings indicate that insufficient technology–organization coordination may cause efficiency gains at individual stages to be accompanied by shifts in organizational workloads. Inadequate technology–environment alignment manifests as temporal misalignment between accelerated disbursement and existing provider payment arrangements, increasing the burden of subsequent payment adjustments. Tensions between uniform institutional requirements and local organizational capacity influence pathway selection and coverage expansion. Coordinating efficiency improvement and fund security requires alignment among technology, organizations, and institutional rules. The study therefore proposes integrating operational processes, improving dynamic monitoring and payment adjustment mechanisms, and strengthening organizational capacity and stakeholder collaboration to support the expansion and operational improvement of prompt settlement reform.