NHCAA 2025: Three market signals redefining fraud prevention and payment integrity

This year’s NHCAA Annual Training Conference made one thing clear: the world of fraud prevention and payment integrity is shifting faster than most plans can keep pace with. Conversations across sessions and the exhibit floor reinforced a shared urgency: AI is reshaping both the threat landscape and the solution ecosystem.

Below are the three biggest takeaways from the event and what they mean for health plans preparing for the next wave of fraud, waste, and abuse (FWA) and payment integrity (PI) challenges.

1. AI-driven fraud is surging—and detection is no longer enough

One of the most consistent themes at NHCAA was the rapid rise of AI-enabled fraud. Fraud teams—especially in Medicaid—reported seeing more AI-generated false claims than ever before. Many of these teams are large operations, yet even they are struggling to keep up. The issue isn’t a lack of effort; it’s that bad actors are adopting automation and generative technologies faster than payer defenses evolve.

As a result, the mindset is shifting: detection alone is no longer enough. Plans are actively seeking prevention-first strategies, powered by modern AI that can spot subtle signals earlier, capture risk upstream, and reduce downstream burden on investigators, auditors, and SIUs. The market is clearly moving toward proactive, intelligent defenses that scale beyond manual review.

2. Claims complexity is outpacing traditional rules-based approaches

Another clear takeaway from NHCAA was the accelerating complexity of claims and audit patterns. Sessions highlighted increasingly complex fraud schemes involving pricing manipulation, transparency gaps, and nuanced interpretations of medical and policy rules.

Traditional rules engines and simple pattern-matching approaches are struggling to keep up. The number of unusual cases is increasing, and many schemes are now hidden in subtle documentation or coding variations that conventional tools overlook. 

This is driving demand for AI that blends three critical domains of intelligence:

• Analytic: to identify deviations and anomalies
• Clinical: to understand what should be happening for a given diagnosis, treatment plan, or patient
• Coding: to interpret the structure, logic, and appropriateness of billed services

Each domain addresses part of the problem, but complex claims increasingly require all three working together to provide context, precision, and defensible reasoning. As regulatory scrutiny intensifies, configurability, transparency, and traceability are becoming table stakes - not differentiators.

3. Health plans are demanding real, transparent AI—not marketing claims

The final central theme at NHCAA was the widening gap between AI marketing and real-world capabilities. Health plans are noticing that while every brand seems to be leaning into AI-heavy messaging, questions remain whether vendors have the tech to back it up. That widening gap between marketing and reality is only creating more fatigue and skepticism among PI and FWA leaders. In a market where many solutions remain opaque or overpositioned, the value of clarity and demonstrability stands out.

As the boundary between fraud prevention and PI continues to evolve, the industry is increasingly interested in solutions that deliver integrated intelligence. There is also a strong emphasis on seeing AI in action rather than simply hearing claims about it, signaling a broader market shift toward practical, verifiable intelligence in PI.

How Cohere approaches AI in PI 

The trends observed at NHCAA underscore the need for more innovative and adaptable solutions across the payment accuracy continuum. Cohere Validate was built for precisely this kind of environment—bringing together analytic, clinical, and coding intelligence within an automated, transparent auditing framework.

Within this platform, the Sepsis Audit Agent provides a targeted, agent-based AI capability designed to address one of the most challenging, variable, and high-stakes audit areas. It adapts to your sepsis policies, automates the most time-consuming parts of the review process, and delivers consistent, defensible outcomes at scale.

Key capabilities include: 

AI-powered, 24/7 audits

• Continuous, autonomous claim reviews, scanning hundreds of pages of medical records.
• Automatically closes non-findings and directs auditors to high-priority cases.

Policy flexibility

• Configurable to Sepsis-3, Sepsis-3 (exclude pre-existing), Sepsis-2, qSOFA, or hybrid frameworks.
• Ensures audits align with your specific clinical and policy criteria.

Unmatched efficiency

• Reduces hours of work to minutes per case.
• Grouper and pricer integrations for real-time DRG updates and instant payment calculations.

Superior accuracy and transparency

• Automates SOFA/qSOFA/SIRS scoring with full audit trails and detailed documentation.
• Eliminates inconsistency and human error, giving auditors clinical confidence.
  

Scalable Support

• Access Cohere’s expert clinical auditors for hybrid or overflow workflows.
• Streamlined processes reduce provider disputes and improve collaboration.

What this means for health plans

NHCAA 2025 underscored a clear reality: AI-driven threats are growing, the PI landscape is converging, and claims are more complex than ever. Health plans also face a critical challenge: not all sepsis cases—or health plan policies—are created equal. This variability makes accurate, defensible audits more difficult, increases the operational burden, and heightens the need for intelligent, adaptable approaches.

Solving these challenges demands more than incremental improvements. Plans need tools that integrate clinical reasoning, policy alignment, and automation to enable faster, more precise decision-making while driving true innovation in high-stakes areas such as sepsis. Cohere Health is uniquely advancing this space with configurable, agentic AI that elevates audit accuracy, consistency, and transparency. Together, these capabilities represent a new standard for payment integrity—one built to keep pace with rising complexity and deliver clarity where it matters most.  

Learn more about AI-powered sepsis auditing and how it can help your team handle complex, high-stakes claims here.