In a sea of sameness, here’s why our AI platform stands out

As healthcare costs in the U.S. continue to soar, health plans are seeking new strategies such as AI-powered automation to improve quality and efficiency, reduce provider abrasion, and support better clinical outcomes. According to a 2025 survey, 84% of health plans use artificial intelligence and machine learning. Among those currently using or exploring these technologies, utilization management (71%) and prior authorization (68%) are the top use cases. 

With AI adoption on the rise, AI is no longer a buzzword—it’s table stakes. Yet not all AI is the same. Many solutions rely on generic large language models (LLMs) or rules engines that don’t reflect the complexity of clinical documentation or real-world UM operations. As a result, health plans may not understand the subtle differences among options or distinguish between those that deliver meaningful insights, reduce administrative costs and provider burden, and save time, and those that offer only surface-level information. Choosing a vendor with the wrong approach can lead to inaccuracies, poor outcomes, higher costs, and compliance and safety risks. 

Here, we help you move beyond the AI hype and explore what makes Cohere Health’s platform for utilization management and payment integrity different from traditional models and other solutions, plus, how we’re delivering tangible outcomes for our health plan partners.

For every $10 billion of payer revenue, AI solutions could save $380 million to $970 million in medical costs, and increase revenues by $260 million to $1.24 billion—McKinsey

Rethinking AI: What makes Cohere Health’s platform different

Many healthcare AI solutions appear to be repurposed from generic tools trained on web or claims data, are rules-based, lack clinical context and auditability, and as a result, don’t deliver measurable outcomes. These solutions create operational inefficiencies, leave health plans vulnerable to quality and compliance risks, and create provider abrasion. Unlike other solutions, AI isn’t merely an enhancement to Cohere’s solution—it’s at the core of everything we do. Here’s how our platform fills the gaps where traditional models fall short.

Built for health plans that demand precision

Unlike rule-based automation or generic large language models (LLMs), our AI is a clinician-trained model that understands context, making it a precision solution for patient-centric care and high-stakes clinical decision-making. Rather than relying on a single LLM, our suite includes hundreds of purpose-built healthcare models. The models are designed, built, trained, and validated by AI experts and UM clinicians to ensure accuracy. We use real clinical documentation and live UM workflows to train and design models for health plan-specific prior authorization and payment integrity, rather than generic consumer- or claims-only workflows. Plus, with continuous retraining, clinician feedback, and more than 30,000 transactions, our model continues to get smarter and perform better. 

‍Transparent and auditable by design ‍

One of the most common barriers to AI adoption is trust. Health plans fear that AI is a black box and can make decisions without providing explanations. Our platform, however, is intentionally designed to be a transparent, explainable system. Our model incorporates oversight and clinician review to ensure that all decisions are transparent and verifiable. Our team of over 150 clinical experts ensures that our solutions are rooted in evidence-based clinical knowledge and expertise. We share the clinical reasoning for our decisions with providers, including cited sources from clinical documents, to either approve or pend for further review. With complete visibility into decision-making, our models have greater transparency than traditional manual processes and opaque AI systems. With deadlines for the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) right around the corner, and health plans required to implement HL7® FHIR® Patient Access API, transparent data exchange will remain top of mind. 

Safe, responsible, and clinically governed

‍As AI adoption grows, so do concerns about security and data governance. AI misuse, errors, and data leakage, among other risks, are top of mind for health plan leaders. Our models are HIPAA-compliant, HITRUST-certified, continuously monitored 24/7, and equipped with safety guardrails to prevent bias, drift, and hallucinations, ensuring the utmost level of accuracy. Most importantly, we never use AI to deny care—only human clinical experts, including MDs, RNs, and specialists, make denial decisions. Our experienced human clinicians also conduct random, daily audits to address unexpected scenarios not accounted for during development. 

‍Customized for each plan—and proven at scale

‍Unlike one-size-fits-all solutions, our models are customized and fine-tuned to the health plan’s guidelines, operational goals, and use cases, while also considering hundreds of clinical factors and millions of healthcare documents. Our models also surpass standard LLMs by extracting more detailed and accurate clinical data. By fine-tuning the models, we can capture specific documentation of a member’s presenting condition—and its associated nuances—with greater accuracy than other models. In fact, our model is 40% more accurate than Llama and 10% more accurate than humans.

Our other outcomes include:

Prior authorization 

• 85% auto-approval rate 
• +5 days faster to appropriate care
• 61% reduction in provider input time and expense

Payment integrity 

• 30-87% improvement in auditor efficiency 
• 45-94% hit-rate improvement 
• 8-9x ROI

Moving beyond the hype ‍

AI is no longer a future promise or a key differentiator, but a business imperative. Clinical-grade healthcare AI that is highly accurate, transparent, auditable, accountable, and fine-tuned helps health plans deliver better outcomes, reduce administrative burden, and strengthen provider relationships. With our healthcare foundation, health plans are moving beyond the AI hype and realizing measurable operational, clinical, and financial outcomes.

‍Want to learn how your health plan can use clinical-grade AI for utilization management and payment integrity? Contact Cohere Health today to schedule a demo.