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From review to revenue: How pre-pay audit unlocked $10M+ in just six months
From review to revenue: How pre-pay audit unlocked $10M+ in just six months
A Medicare Advantage health plan proved precision doesn't have to slow pre-pay review down—identifying more than $10M in savings in six months.
Published: September 21, 2026
Topics:
Payment Integrity
Health Plan
Medicare Advantage Plan
The Challenge
The Challenge
High-cost drug and durable medical equipment (DME) claims sit at the intersection of two competing pressures: they carry some of the highest per-claim financial risk in a payment integrity program, and they move on a pre-pay timeline that leaves little room for delay. Getting it right requires reviewing the right claims, with the right clinical rationale, fast enough to keep pace with payment cycles—all without creating friction for providers.
For this Medicare Advantage health plan, high-cost claims required more targeted oversight than a broad-based review approach could deliver. The organization looked to a specialized payment integrity partner to bring that level of precision to its pre-pay program. The partner needed to improve accuracy while minimizing provider friction, ensuring a clinically defensible review process at scale, without delaying the pre-pay cycle.
The opportunity focused on combining speed, precision, and clinical accuracy into a single, scalable program.
Cohere Health's Opportunity
Deliver faster, more precise clinical validation
in a single, scalable pre-pay program.
Sharpen findings
while minimizing provider friction.
Scale clinically defensible review
across high-cost drug and DME claims.
The Solution
The Solution
To meet the demands of a pre-pay environment, the health plan implemented Cohere Validate to deliver end-to-end services, starting in the first pass for high-cost drug (HCD) and DME claims.
The process begins with Cohere Health's smart selection technology, which analyzes the full claims population to identify which claims are most likely to contain genuine billing issues. Selection isn't static: it accounts for each provider's documentation history and audit track record. Providers who consistently submit accurate, well-documented claims are reviewed less frequently, while review resources are focused where errors are more likely to occur. Selections also respect payer-imposed caps on audit volume per provider, ensuring the program stays aligned with the excellent care providers deliver to patients.
After claims are selected, the medical record retrieval process keeps pace with the compressed timelines demanded by pre-pay reviews. From there, Cohere Health's AI agents read the corresponding records at scale, rapidly surfacing the claims that warrant closer review and returning clean claims to the plan without delay.
For claims with confirmed findings, Cohere Health issues letters to providers grounded entirely in established guidance—CMS rules, payer policy, or contractual terms. Each letter includes a detailed clinical summary of the audit rationale, showing providers exactly where documentation fell short and which rule the finding is based on. There's no ambiguity about how a determination was reached—every finding traces back to a clear, citable source. That transparency does double duty: it makes findings highly defensible, and it gives providers the specific information they need to correct billing practices going forward—turning every audit into an opportunity for provider education.
There's no ambiguity about how a determination was reached—every finding traces back to a clear, citable source.
The Cohere Health Difference
Intelligent claims selection
AI/ML continuously analyzes claims to surface high-value savings opportunities
Provider history and audit track record inform selection—reducing review frequency for consistently accurate providers
Models are continuously refined based on results—growing more precise over time
Precision AI
AI agents read medical records at scale, pre-screening for issues before auditor review
Clean claims are returned to the plan quickly, without unnecessary provider outreach
Audit rationale is auto-generated and parsed into a letter template
Transparent findings
Findings grounded in clinical evidence and payer policy with clear rationale
Root cause explanations pinpoint the billing issue for improved provider education
Detailed findings documentation ensures audit results are highly defensible
Technology-powered services
Technology and in-house clinical and coding experts work as one team—not a layer of outsourced reviewers working separately
Same proprietary models that power the platform intelligence also support every review, validation, and finding—no hand-offs between disconnected systems or teams
Reviewer expertise sharpens the technology, and the technology sharpens reviewer focus—each gets better and more precise as the program runs
The Results
The Results
$10M
in identified savings over 6 months
48%
finding rate across selections
<2%
appeal rate
In just six months, the program identified more than $10M in savings. The numbers reflect a program built for both precision and speed.
A 48% finding rate across selections is a strong result on its own—and it's even more notable given the program's pace and volume. That precision carries through to the appeal rate: at under 2%, it's a clear signal that findings are transparent and well-supported—making them difficult to dispute and easier for providers to accept.
Beyond the numbers, the program's approach to provider relationships stands out. By factoring in provider history and documentation quality into claim selection and grounding every finding in a clear, evidence-based rationale, Cohere Health built a review process that strengthens payment accuracy. The result is a program providers can trust, even when it flags an issue.
By combining intelligent claim selection, precision AI, and transparent, evidence-based findings, Cohere Health demonstrated that a pre-pay payment integrity program doesn't have to trade speed for precision—or precision for provider trust.
Getting it right requires reviewing the right claims, with the right clinical rationale, fast enough to keep pace with payment cycles—all without creating friction for providers.
The results presented in this case study reflect the experience of a single health plan engagement over a defined period and are based on internal Cohere Healthengagement data. These results are not guaranteed.
