What agentic AI means for health plans: Insights from Gartner® 2026 Research

Health plans have been known to move cautiously with emerging technology. However, the 2026 Gartner® research, Predicts 2026: U.S. Healthcare Payers Bet Big on Agentic Workforce* report, in our opinion, points to a meaningful shift, as agentic AI moves from experimentation to a core component of transformation strategies.

Under sustained cost pressure, regulatory complexity, and mounting administrative burden, health plans are accelerating investment in AI, particularly agentic AI: systems designed to autonomously execute tasks, orchestrate workflows, and connect fragmented data across clinical and administrative operations. Providers appear ready for this shift—recent survey data shows 99% of clinicians and 96% of office administrators are comfortable with AI assisting in prior authorization decisions when appropriate safeguards are in place.

We feel the Gartner message is clear: agentic AI has the potential to fundamentally reshape how health plans operate. But realizing value—especially in high-stakes workflows such as utilization management (UM), prior authorization (PA), and claims—will depend less on ambition and more on trust, transparency, and how effectively AI extends human expertise without introducing new operational friction.

Below are the key takeaways for plans as they evaluate agentic AI strategies heading into 2026:

1. Health plans are increasing their investment in agentic AI

The share of organizations investing in new technology for business and IT transformation jumped “from 15% in 2024 to 52% in 2025”, in our opinion, signaling a growing willingness to accept risk in pursuit of operational gains.

“All respondents also indicated they have already implemented or plan to deploy agentic AI by 2028.” To us, this urgency reflects reality on the ground. Manual, document-heavy processes—especially in UM and PA—remain costly, slow, and a major source of provider abrasion, often delaying access to care and creating uncertainty around clinical decision-making. Health plans increasingly see agentic AI as a way to move beyond incremental automation toward end-to-end workflow transformation.

The question for plans is no longer whether to invest in agentic AI, but how to deploy it responsibly and at scale.

2. Fragmented data is the core problem agentic AI is meant to solve

Despite years of digitization, payer data remains deeply fragmented. Clinical data, claims, eligibility, benefits, and social determinants often live in separate systems that don’t communicate well, if at all.

To our understanding, Gartner discusses this fragmentation as one of the biggest barriers to efficiency, particularly in workflows like prior authorization that require:

• Clinical context
• Benefit and eligibility verification
• Medical policy interpretation
• Administrative decision-making

Agentic AI introduces a new architectural approach. Rather than forcing organizations to “rip and replace” legacy systems, agents can:

• Act as translation layers between old and new platforms
• Pull data from multiple sources into a unified interface
• Orchestrate multi-step workflows across systems in real time

For UM and PA, this opens the door to more automated, context-aware reviews—without requiring every system to be perfectly interoperable on day one.

3. Automation alone won’t fix trust—especially in prior authorization

One of the more sobering insights from Gartner for us is that automation does not automatically translate into better experiences. “By 2028, Gartner predicts that AI agents and chatbots will handle 80% of member, provider, and purchaser inquiries. Yet overall spend may still rise due to fragmented experiences that erode engagement and trust.” 

In our opinion, this tension is especially relevant in the context of prior authorization. While faster responses and 24/7 access matter, provider trust is shaped by the entire PA experience.

At Cohere, we understand that poorly implemented AI agents introduce meaningful risk. Inaccurate or incomplete responses can undermine credibility, while opaque decision logic may reinforce perceptions of “black box” decision-making. In UM and PA, trust is earned through clarity, consistency, and clinical alignment, not speed alone.

4. Interoperability is becoming an AI problem

Gartner predicts that by “2027, 30% of payers will address critical interoperability challenges using AI and agentic AI, optimizing payer-provider clinical and administrative workflows and reducing manual workloads by 40%.”

In our opinion, this shift reflects a practical reality: interoperability enables data exchange, but value depends on the ability to activate and orchestrate that data within operational and clinical decision workflows. Similarly, regulatory mandates such as CMS-0057-F increase pressure to share information, but they do not guarantee that the data exchanged is usable, timely, or integrated into operational processes. 

Agentic AI has the potential to bridge this gap by interpreting data across disparate formats and systems, coordinating payer-provider workflows in near real time, and automating prior authorization, claims processing, and payment integrity. However, in our view, Gartner cautions that success depends on strong data quality, governance, and human oversight, particularly in regulated workflows that directly affect access to care.

5. Claims and prior authorization are converging through AI

Another notable theme in the report is the growing convergence of clinical and administrative data. Gartner predicts that by 2028, “80% of ambulatory claims will be processed through AI-enabled, real-time adjudication.” 

This trend reinforces the importance of connecting UM, PA, and claims workflows. When clinical documentation, authorization decisions, and claims adjudication operate in silos, inefficiencies compound for both plans and providers.

Meaningful transformation in PA and claims depends on linking clinical and administrative workflows to create coordinated systems that reduce friction throughout the care journey.

What this means for health plans in 2026

In our opinion, the Gartner 2026 insights point to a clear conclusion: agentic AI has transformational potential, but only for organizations that invest with intention.

For health plan leaders, especially those responsible for utilization management and provider experience, that means:

• Prioritizing AI-ready data foundations
• Designing workflows with human-in-the-loop oversight
• Focusing on end-to-end experiences, not isolated use cases
• Proving ROI incrementally while building organizational trust

Where Cohere Health fits in the agentic AI future

Gartner's 2026 predictions, to us, reinforce a reality many plans are already confronting: automation alone isn’t enough. At Cohere Health, we believe that the value of agentic AI—particularly in high-impact workflows such as utilization management and prior authorization—depends on solutions that work with, not against, existing health plan and provider ecosystems.

Cohere Health’s approach reflects this reality. Rather than treating agentic AI as a standalone capability, Cohere focuses on applying clinically grounded AI where it matters most. That begins with higher-accurary clinical AI designed to reason over complex, unstructured documentation—helping to surface relevant evidence that might otherwise be lost across siloed workflows or overlooked by general-purpose models. 

Equally important, these capabilities are embedded within an end-to-end platform purpose-built for real-world utilization management and prior authorization workflows. Developed with clinicians and aligned to the realities of care delivery, this approach helps ensure AI augments human expertise, supports consistent decision-making, and integrates seamlessly into existing operations.

As agentic AI moves from experimentation to enterprise strategy, the organizations that succeed will be those that deploy it not simply to automate tasks, but to strengthen trust, improve consistency, and reduce friction across the healthcare ecosystem.

* Gartner, Predicts 2026: U.S. Healthcare Payers Bet Big on Agentic Workforce, By Faith Adams, Austynn Eubank, Connie Salgy, 15 December 2025, ID G00839721.

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