What Changed at Cohere Health

Cohere Health published performance results for Cohere Capture, which extracts HEDIS gap closures and denominator exclusions from clinical data a health plan already holds, including prior authorization notes, imaging reports and EHR data. Cohere reports an average 15 percent improvement in Stars performance per measure, 107 gaps closed per 1,000 members with records, and a minimum 5 to 1 return on a pay for performance model.

Our read

These figures are vendor reported and the release does not describe how they were measured. Plans should ask for the method and baseline behind the 15 percent figure, and how much of the lift comes from prior authorization records Cohere already sees as the plan's utilization management vendor.

Cohere Health acquired ZignaAI in September 2025 and launched the Cohere Payment Integrity Suite, extending its clinical AI from pre service prior authorization into post service claims and coding validation. The company subsequently launched specialized audit agents for high cost conditions including sepsis, reporting a 58 percent findings rate, and states the combined pre and post service view achieves up to 9x return on investment.

Our read

Two things matter here beyond the acquisition itself. First, scope creep across the claim lifecycle: a platform that decides authorization before care and then audits payment after care sits on both sides of the same clinical event, which is efficient for the plan and worth examining for providers, since the evidence surfaced at authorization is explicitly reused to validate the claim. Second, the audit agents carry a stated 58 percent findings rate on conditions like sepsis. A findings rate is a measure of how often the model flags something, not how often it is right, and sepsis coding is among the most contested areas in payment integrity. Plans should establish the confirmation rate on appeal, not just the findings rate, before treating that number as savings.