Driving proactive payment accuracy with Cohere Match™

Entering 2026, health plans are operating in an increasingly complex environment marked by rising costs, ever-changing regulatory requirements, and manual, inefficient processes at every turn. The fragmentation between utilization management (UM) and payment integrity (PI), and the lack of alignment between prior authorizations and claims, can contribute to overpayments, though they are only two of many factors. Highlighting this connection early allows health plans to explore ways to shift some savings upstream and prevent errors before payments are made.

According to a 2025 survey, 70% of healthcare executives expect disruption over the next 2 to 5 years, driven by regulatory uncertainty, emerging technologies, and competitive pressure, including AI, automation, and analytics. For many health plans, this anticipated disruption could accelerate efforts to modernize operations, reduce reliance on manual workflows, and better connect decisions made across the care and claims lifecycle. 

One of the most costly and persistent challenges sits at the intersection of UM and PI. When prior authorization decisions and claims processing operate in silos, mismatches occur—leading to overpayments, unnecessary administrative work, strained provider relationships, and delayed reimbursements. As claim volumes and complexity increase, health plans need a more connected, proactive approach to ensure payment accuracy before dollars are disbursed.

80% of healthcare leaders cite regulatory and policy changes as a top strategic priority in 2026—Deloitte

Overpayments remain a persistent challenge

Traditional, siloed UM and payment integrity programs sometimes struggle to reconcile prior authorizations with submitted claims accurately and consistently. Authorization statuses change, claims may be resubmitted multiple times, and matching logic requires constant maintenance. When this reconciliation fails, auto-adjudication rates decline, and manual review volumes rise. 

The mismatch can occur for several reasons. For example, prior authorizations and claims can have multiple submissions and statuses. Matching rules are complex and need consistent maintenance. Manual processes can also introduce errors. Incorrect and missed matches result in a high volume of unnecessary manual claims and UM reviews, increasing administrative burden and costs, and delaying payments. 

When overpayments are identified and clawbacks occur, providers lose trust, and relationships become strained. Health plans typically rely on processes that address this alignment gap only after the fact through retroactive reviews and post-pay audits. Instead of proactively preventing overpayments, they often end up scrambling to recoup dollars after they’ve already been paid out.

As claim volumes continue to grow and regulatory scrutiny intensifies, health plans are seeking new solutions that shift payment integrity earlier in the process—preventing overpayments, reducing manual processes and retroactive interventions, and improving provider relationships.

Aligning utilization management with payment integrity

Cohere Match™, part of our Payment Integrity Suite, is a claims-to-authorization reconciliation solution designed to help prevent overpayments before payment occurs. By connecting rich clinical authorization data captured during utilization management with downstream claims processing, the goal of Cohere Match™ is to enable health plans to move from reactive recovery to proactive payment accuracy. This allows health plans to ensure the right authorization is applied to the claim, improving accuracy while maintaining efficiency. 

Some of the key benefits of Cohere Match™ include:

Improved team efficiency‍
By minimizing retro authorizations, manual authorization matching, and post-pay audits, Cohere Match allows auditors to focus on true exceptions so they work smarter—not harder.

Improved payment accuracy and savings
Our clinical intelligence, powered by AI-driven analysis of large datasets, predictive analytics based on clinical and demographic data, and evidence-based guidelines, enables health plans to identify when code variations are clinically appropriate or when they represent upcoding or unbundling. Instead of simply identifying an authorization, the solution identifies the correct authorization, enabling higher auto-adjudication rates for legitimate claims while also flagging real issues and mismatched or missing authorizations before payment.

Authorization data integration
By harnessing rich clinical prior authorization data before services are delivered, overpayments can be prevented at the source. Claims are scored against authorizations using multiple criteria, providing transparency, confidence, and detailed insight into decisioning. 

Stronger provider partnerships‍
Fewer post-pay audits, denials, and duplicate medical record requests mean less provider abrasion. By addressing discrepancies in pre-payment, health plans can improve trust, collaboration, and timeliness.

Upstream intervention and insight ‍
By identifying mismatch patterns early, Cohere enables health plans to educate providers on documentation best practices and optimize prior authorization and claims workflows to ensure appropriate reimbursement.

Cohere Match bridges utilization management and payment integrity through shared clinical and authorization data, enabling health plans to proactively prevent overpayments, ensure fast, accurate reimbursement, and reduce provider abrasion—without relying on costly, reactive recovery programs.