Executive Summary

Cohere Health is a fast-growing healthcare technology company (founded circa 2019–2020 in Boston) that has built an AI-powered “clinical intelligence” platform to revolutionize prior authorization (PA) and utilization management for health plans and providers. The company’s solutions automate both payer and provider workflows, shifting PA from a bureaucratic hurdle to a value-added component of the care journey (^[1]) (^[2]). Using clinician-crafted AI models and evidence-based care guidelines, Cohere’s platform enables up to 90% of authorization requests to be approved automatically and processes millions of PA requests annually (^[3]) (^[4]). Early results from major customer pilots indicate significant clinical and financial impact: for example, Geisinger Health Plan (GHP) reported ~15% reduction in total medical expenses and a 63% cut in PA denials after deploying Cohere (^[5]) (^[6]). Health plans and providers also report dramatic efficiency gains (e.g. 70% faster care delivery, 40–55% less provider time on PA, and 93–98% satisfaction (^[7]) (^[5])). Cohere has attracted top investors and won industry awards for its “next-generation” approach: in May 2025 it closed a $90 million Series C (led by Temasek) bringing total funding to ~$200 million (^[8]), and in 2022 a Cohere–Humana–provider partnership won a KLAS “Points of Light” award for transforming the PA process (^[9]) (^[10]).

This report provides an in-depth analysis of Cohere Health’s origins, strategy, products, and impact. We begin with background on the PA challenge in U.S. healthcare, followed by a history of Cohere’s launch and growth. Then we detail Cohere’s solution suite – including its core platform, prior authorization automation, and delegated utilization management and payment integrity services – with data on performance and case-study outcomes. Finally, we discuss market context, implications of AI-driven PA, and future directions. All assertions are backed by published sources: industry news, peer analyses, regulatory reports, and Cohere’s own press releases.

Introduction and Background

The U.S. healthcare system has become notorious for cumbersome prior authorization processes, which require clinicians to obtain insurer approval before many tests, prescriptions, and procedures. According to surveys by the American Medical Association (AMA) and specialty societies, the vast majority of physicians (over 90%) report that PA delays care and increases administrative costs (^[11]). For example, an AMA news release in August 2024 found “nearly 90% of physicians surveyed reported that prior authorization leads to higher overall utilization of healthcare resources”, with the result that 69% saw ineffective initial treatments, 68% extra office visits, 42% more emergency visits, and 29% hospitalizations as a consequence (^[11]). In other words, PA bottlenecks can worsen patient outcomes and ultimately raise costs rather than save them (^[11]).

These burdens have prompted calls for reform at all levels. Regulators (e.g. a final CMS Interoperability & PA rule, CMS-0057-F) now require health plans to adopt standardized electronic PA workflows (FHIR-based APIs) by 2024–2026 in order to reduce friction. Industry groups like AHIP and CMS jointly pledged in mid-2025 to accelerate PA modernization across all major plans (^[12]) (^[13]). Nonetheless, fully automating PA is complex: it involves translating clinical policies into machine-readable form, integrating with diverse electronic health record (EHR) systems, and ensuring that evidence-based care guidelines guide decisions. Many existing “robotic” PA solutions simply streamline paperwork or fill forms, but leave major clinical and administrative impediments in place.

Cohere Health emerged to address these challenges by reimagining PA as a collaborative care-management tool rather than a gatekeeping chore (^[1]) (^[9]). Its founders observed that traditional PA is reactive and siloed, requiring separate interactions for each step of a patient’s treatment path. Cohere instead builds “episode-of-care” authorizations: the platform can pre-approve an entire course of treatment (e.g. from diagnostic workup through surgery and rehabilitation) in one integrated workflow (^[14]). The goal is to align patients, providers, and payers on an optimal care plan – delivering the “right care, at the right time, in the right place, and with the right value” (^[15]) (^[16]). In doing so, Cohere leverages AI to automate the bulk of routine decisions (up to 90% auto-approval rates (^[3])) while reserving human oversight for complex cases. This clinician-led, responsible-AI approach has been described by Cohere’s CEO as key to “bringing real clinical intelligence to the table”, differentiating its solution from purely rules-based or “patchwork” systems (^[17]).

Below we trace how Cohere has grown from a small startup to a category leader in AI-driven utilization management (UM).We then examine its product suite in detail, contrasting its services to the legacy approaches it replaces, and review evidence (data, case studies, and expert commentary) of its impact on care efficiency and quality.

Company History and Growth

Founding and Management. Cohere Health was co-founded around 2019–2020 by Siva Namasivayam, a healthcare technology veteran (former founder/CEO of SCIO Health Analytics, which was acquired for ~$240M (^[18])). Namasivayam serves as Cohere’s CEO and co-founder (^[19]). His vision – as he has recounted in interviews – was to apply modern analytics and collaboration to end the adversarial PA dynamic. Under his leadership and with input from a medical advisory board, the company developed its first platform (initially called CohereNext or Cohere Unify) and began pitching it to payers in 2020, starting with a focus on complex specialties (e.g. musculoskeletal care) where clear clinical guidelines exist (^[14]) (^[20]).

Funding Rounds. Cohere has raised multiple rounds of private financing to fuel growth. In early 2021 (less than a year after its launch), Cohere closed a $36 million Series B round led by Polaris Partners (with participation from Flare Capital, Longitude, Deerfield, etc.) (^[21]). This followed a smaller Series A in 2020 (at least $10M, including an extension) (^[22]). The capital enabled Cohere to expand its engineering and clinical staff (from under 10 employees in Jan 2020 to over 700 by 2024 (^[23])) and to deepen partnerships with health plans. Additional growth rounds followed: in February 2024 Cohere announced a $50M equity raise (led by Deerfield Management) to meet surging demand under the new CMS PA rule (^[24]). Most recently, in May 2025 Cohere closed a $90M Series C led by Temasek (Singapore’s sovereign fund), bringing total funding to roughly $200M (^[8]). Altogether the company has raised on the order of two hundred million dollars in venture capital, underscoring investor confidence in its model. (Investors have cited Cohere’s unique embedding of clinical expertise in PA automation as a key differentiator (^[17]) (^[25]).)

Key Partnerships and Alliances. Cohere has forged notable strategic partnerships to validate and expand its offerings. In late 2020, Humana announced a collaboration to use Cohere’s platform for musculoskeletal treatments in 12 states, covering ~2 million members and 3,500 physician practices (^[26]) (^[27]). This pilot pre-authorized entire “episodes” (e.g. knee surgeries) rather than isolated procedures – an early proof of concept for Cohere’s model. In mid-2022, Geisinger Health Plan (a Pennsylvania insurer covering >500,000 members) adopted Cohere to support its value-based care program (^[28]). A joint press release highlighted that Cohere’s system would provide “evidence-based, proactive care suggestions” to providers, reducing hand-offs and denials on the way. More recently, Cohere announced a partnership with MCG (formerly Milliman Care Guidelines) in October 2024 to integrate MCG’s clinical criteria into Cohere’s PA workflows, further strengthening its evidence base.

Industry Recognition. Cohere has rapidly earned recognition in the health IT community. In mid-2022 the KLAS research group awarded Cohere (in conjunction with Humana and provider partners) a “Points of Light” award for a PA collaboration that “reduced the burden of prior authorization and sped patient access to quality care” (^[29]) (^[9]). Reviewers particularly cited Cohere’s elimination of unnecessary pre-approvals and streamlined workflows for top-performing providers (^[10]). The company has also been named among top health-tech startups (e.g. a LinkedIn “Top 5 Startup” in digital health) and appears in analyst reports (e.g. Gartner Hype Cycle 2024/25 for U.S. Heathcare Payers) (^[30]) (^[31]). These accolades reinforce Cohere’s status as a category innovator.

Timeline of Major Events: The table below summarizes Cohere’s growth milestones and funding:

Products and Services

Cohere’s offerings center on a unified platform that combines AI, analytics, and human review to optimize utilization management. At a high level, Cohere classifies its solutions into two main categories: (1) Utilization Management / Prior Authorization, and (2) Payment Integrity (Claims Audit). The underlying platform (often referred to as Cohere Unify or Intelligent Prior Authorization Platform) orchestrates data exchange and decision support between payers and providers. Key components and products include:

• AI-powered Prior Authorization Automation: This is Cohere’s core offering. It includes real-time processing of PA requests, automated decision support, and clinician-assisted approvals. Cohere’s AI models (trained on clinical guidelines and historical claims data) handle the bulk of authorization decisions, while flagged cases are routed to on-staff nurses or specialty physicians for review. The system is EHR-integrated and supports inputs via EMR, fax/phone, or portals. Notable features:

• Auto-approval: Up to 90% of routine requests can be instantly approved by the system without human intervention (^[3]). (Cohere reports that no claim is denied solely by AI – every decision is overseen by a specialist (^[4]).)

• Episode-of-care approach: Instead of separate approvals for each procedure, Cohere can pre-authorize an entire care path (e.g. tests, surgery, rehab) in one workflow (^[14]).

• Provider “Co-pilot” guidance: Embedded in the workflow are suggestions and prompts (based on evidence-based medicine) to nudge physicians toward high-value options before submission. For example, in a Geisinger pilot the platform recommended more conservative therapies first, leading to a 15% net savings in medical spend (^[5]).

• Delegated Utilization Management (“Cohere Complete” for UM): Cohere can take over a health plan’s UM operations entirely. In this model, Cohere’s team of RNs/MDs and AI tools manage end-to-end PA for select specialties. Cohere reports that this delegated service achieved >50% fewer denials overturned on appeal (since requests were more complete) and up to $4.56 PMPM savings on medical benefit expenses in a national cardio UM program (^[34]). Physicians using Cohere Complete experienced 93% satisfaction and 96% digital adoption, with PVs spending 40% less time on authorizations (^[35]).

• Prior Authorization Personalization (Cohere Align™): Launched in 2025, Cohere Align is a “smart waiver/green-lighting” solution that personalizes the PA process. By analyzing providers’ historical behavior and performance, it identifies trusted clinicians (for example, those who consistently follow guidelines) and dynamically adjusts their PA requirements. According to Cohere’s press release, this approach resulted in ~80% of PA submissions being streamlined for pre-approved providers (with minimal extra steps), cutting provider submission time by 55%, and yielding a 98% provider satisfaction score (^[7]). Importantly, Align keeps doctors in the loop; rather than issuing blanket waivers, it delivers tailored prompts and dashboards so that high-volume providers can focus on patient care (aligning with demands for better provider experience (^[36]) (^[7])).

• Interoperability APIs (Cohere Connect™): To comply with CMS mandates and improve end-user experience, Cohere introduced Cohere Connect in 2025. This is a suite of FHIR®-standard APIs (Coverage Requirements Discovery, Documentation Templates/Rules, and PAS APIs) that allow providers to initiate PAs directly from their EHRs (^[33]). Cohere claims these APIs have already supported over 6 million PA submissions, with workflow-based guidance (e.g. web forms and SMART-on-FHIR integration) to help providers submit complete information (^[33]) (^[37]). The goal is seamless EMR-to-payer transmission of authorization requests, minimizing duplicate data entry. The press release notes that Cohere achieved ~96% digital adoption of its platform (i.e. nearly all transactions through electronic channels) and a provider NPS of 64 (^[38]).

• Payment Integrity / Claim Audit Solutions: Beyond PA, Cohere offers products to modernize claim audit and payment integrity. The Cohere Validate product is an AI-driven audit tool for in-house use: it scans claims and medical records to flag high-risk cases and automate complex audits. Cohere reports that Validate can yield up to $96 per member per year (PMPY) in recoveries in the first year of deployment, with a 14% higher hit rate on audit findings compared to traditional methods (^[39]). For plans that outsource audits, Cohere Complete for PI provides end-to-end managed services. This service combines Cohere’s AI triage with expert coding audits and appeals. According to Cohere, the outsourced PI service delivered a 30% increase in auditor efficiency vs. legacy vendors, along with high provider satisfaction due to a consultative rather than punitive approach (^[40]). Another component, Cohere Match, cross-references authorization records and payments to catch mismatches before claims are paid.

In summary, Cohere’s product suite spans the full authorization and auditing lifecycle: from initial request intake (via Connect APIs or other submissions), through real-time AI review, to peer-to-peer appeals and audit. The platform is powered by extensive clinical content (e.g. specialty-specific guidelines and evidence) and machine learning models fine-tuned to each plan’s policies. Figure 1 below lists key offerings and their roles:

Data Analysis and Performance

Clinical and Financial Impact: Cohere provides evidence that its platform delivers both cost savings for payers and faster care for patients. In the Geisinger Health Plan case study, Cohere reported an average 15% reduction in medical expenses (compared to prior methods) and a 63% reduction in denial rates after examing authorizations for its first focused program (^[5]). Nearly all submissions were processed electronically (95% digital submission rate), with immediate-approval decisions expediting patient care by 70% faster than the old system (^[6]). Moreover, GHP saw an 18% drop in surgical complication rates, attributed to better-aligned treatment plans and earlier interventions (^[6]). A KLAS analysis of Cohere’s Humana pilot also noted that shifting many procedures from inpatient to outpatient settings contributed to improved outcomes (^[10]) – a hallmark of higher-value care.

For providers, direct feedback has been overwhelmingly positive. Cohere cites an aggregate 93–98% provider satisfaction across its deployments (^[41]) (^[7]). In practice, clinicians saved significant time: one report showed a 40–55% reduction in physician time spent on PA tasks when using the Cohere system (^[42]) (^[7]). In a broader industry survey conducted by Cohere, 99% of physicians and 96% of office staff said they “trust AI when used appropriately” in PA decision-making (^[43]). This suggests that Cohere’s clinician-centric design (with human oversight and transparent logic) achieves buy-in from users.

Quantitatively, Cohere’s platform achieves extremely high throughput. As of 2025, the company processes over 12 million PA requests per year on behalf of its clients (^[4]). According to CEO Siva Namasivayam, roughly “85% of authorizations receive an immediate determination (approved or flagged) by AI,” with the remaining 15% handled by peer review doctors or nurses (^[4]). Even when review is needed, Cohere’s AI “co-pilots” pre-populate work sheets to speed decisions. The authoritative press notes that “no claim is denied exclusively by AI” (^[4]), underscoring the hybrid model. These efficiencies translate to plan savings; firms like Polaris Partners highlight that Cohere’s technology “fundamentally changes how clinical decisions are made” by aligning evidence and avoiding unnecessary denials (^[25]).

Regulatory and Compliance Outcomes: Cohere’s investments in interoperability have yielded major compliance results. The June 2025 industry pledge set targets such as “80% of PAs decided in real time” and universal FHIR API use. Cohere reports that it already exceeds these goals: 85% of prior auths are handled in real time (meeting the 80% target) and its systems processed 9 million FHIR-based authorizations in the last year (^[13]). On average, provider data-entry time fell by 61%, and AI acceleration made medical necessity reviews 50% faster (while maintaining >99% accuracy) (^[13]). In aggregate, Cohere’s clients see roughly 93% provider satisfaction across 600,000+ clinicians supported (^[13]), indicating that efficiency gains are not sacrificing quality. These figures not only cement Cohere’s leadership in meeting new PA mandates, but also suggest that broader “prior auth reform” goals (reduced friction, greater transparency) are being achieved in practice.

Competitive Positioning: Cohere’s unique value proposition has been noted by industry analysts. Unlike “touchless” PA solutions that only automate form-filling, Cohere’s clinically intelligent approach has been described as “transformational” (^[25]). Its emphasis on transparency and evidence has earned it top awards and top-tier funding rounds, in a market where other AI startups (e.g. Olive, Redox, etc.) are also active. Importantly, Cohere’s publicly-quoted results (auto-approve rates, satisfaction, savings) are unusually strong: for example, a 93–98% satisfaction rating in healthcare IT is exceptionally high. On the payer side, CFO-level stakeholders have noted Cohere’s “time-to-value” advantage over legacy tech: clients report immediate admin savings and the prospect of medical expense savings (^[1]). All these data points indicate that Cohere has moved beyond a conceptual innovation to a proven enterprise solution.

Case Studies and Examples

To illustrate Cohere’s impact “on the ground,” we highlight a few real-world deployments:

• Geisinger Health Plan (Pennsylvania): Cohere partnered with GHP in 2022 to enhance its utilization management across multiple lines (commercial, Medicaid, Medicare Advantage). Public press reports from the joint announcement described strong initial outcomes: the platform ensured PA requests were evidence-based, delivering clinical guidance upfront. As a result, GHP realized ~15% incremental medical savings on these cases and slashed denial rates by 63% (^[5]). Moreover, the deployment digitized nearly the entire PA workflow (95% digital submissions) which, combined with AI review, sped patient access by 70% (^[6]). Even seemingly downstream metrics improved – surgical complications fell by 18% after Cohere’s intervention (^[6]). Geisinger’s Chief Medical Officer praised Cohere for improving both provider experience and alignment with value-based care objectives (^[44]) (^[5]).

• Humana (Musculoskeletal Pilot): In its large PA collaboration, Humana reports that Cohere’s episode-approval model made a “straight line” from diagnosis to recovery for patients (^[45]). By pre-authorizing complete treatment plans, Humana could emphasize conservative therapies and avoid unnecessary escalations. Fiona Shrank (Humana CMO and Cohere board member) noted that this co-designed solution “focuses on driving evidence-based, guideline-driven care” while removing administrative obstacles (^[45]) (^[16]). Although detailed metrics from this pilot have not been independently published, the project’s recognition by KLAS (as noted above) indicates measurable spending reductions and provider time savings (^[10]).

• KLAS “Points of Light” Collaboration: KLAS Research described a Cohere-driven PA project (with Humana and providers) that exemplified Cohere’s approach (^[9]). The judges specifically cited improvements in five domains: (1) care quality – for lowering surgical complication rates and shifting procedures to outpatient settings; (2) patient experience – for enabling faster access to care; (3) efficiency – for reducing documentation and admin burden for payers; (4) provider experience – for minimizing peer-to-peer reviews and PA workload; and (5) financial results – for generating medical expense savings (^[10]). This holistic accolade affirms that Cohere’s technology can deliver on the triple aim of healthcare (better care/experience, lower cost) while also benefiting plan administrators and clinicians.

In brief, these cases demonstrate how Cohere’s data-driven interventions lead to specific outcome improvements. In each example, clinical efficiency gains (auto-approvals, digital workflows) translated into faster treatment and lower unnecessary utilization. Financially, the platform simultaneously unlocks savings in both clinical spend and administrative expense. Importantly, providers report minimal disruption – in fact, many describe the new PA process as “forgiving” and “supportive” compared to the old system.

Discussion and Future Directions

Cohere Health’s trajectory reflects broader trends in healthcare and AI. Its success highlights that prior authorization can be transformed through technology and collaboration. Regulatory momentum (CMS rules, state reforms, AMA lawsuits) is pushing payers toward digital, evidence-based PA. Cohere’s clinician-centric AI approach is well-aligned with these forces. As noted by health IT experts and investors, unlike one-size-fits-all AI, Cohere’s solutions are “fine-tuned by medical specialty and business rules” with board-certified doctors in the loop (^[46]) (^[43]). This has earned trust: in a Cohere survey, virtually all doctors (>99%) expressed confidence in AI’s role as long as it remains a support tool (^[43]).

Looking ahead, Cohere is poised to leverage generative AI and expanded data sources. Its marketing materials mention “advanced LLMs” assisting in approvals while clinicians focus on judgment (^[47]). We may anticipate further integration of natural language models to parse clinical notes, FDA labels, and even patient preferences. On the platform side, Cohere’s executives have signaled interest in small acquisitions to broaden domain expertise (^[48]), perhaps in pharmacogenomics or remote monitoring.

The expansion beyond PA is also notable. The same platform that manages PA can in principle support care management (e.g. follow-up protocols) and real-world evidence generation. In fact, the press release hints at “additional clinical use cases” beyond authorization (^[49]). Given its data on authorized episodes, Cohere could eventually provide analytics on treatment patterns and outcomes, feeding back into quality improvement.

However, challenges remain. Some critics point out that AI models trained on historical data may reinforce existing biases (e.g. underuse in certain populations) unless carefully monitored. Cohere acknowledges this risk by emphasizing transparency and human oversight (^[46]). Another issue is the looming reduction of PA requirements announced by some payers (e.g. Humana will cut ~1/3 of PA rules by 2026, per Reuters July 2025 (^[50])). While reducing needless PA is positive, the remaining PA tasks are likely to become more focused on clinical nuance – which plays to Cohere’s strengths (highly tailored, clinician-guided AI).

From the payer’s perspective, Cohere’s model also interacts with payment reform. By delivering “medex savings” that count toward medical loss ratios, Cohere can finance itself as a quality improvement program rather than a fee-per-case vendor (^[35]). This aligns incentives for Medicare Advantage and other value-based payers.

In short, Cohere Health represents an emerging blend of clinical insight, AI technology, and policy awareness. As the healthcare industry increasingly recognizes that the old PA processes are untenable, Cohere’s success suggests a new paradigm: computed collaboration. Rather than battling over authorizations, payers and providers can share data and logic through a platform that makes PA meaningful – driving appropriate care rather than merely checking boxes. If Cohere’s published outcomes (e.g. 15–18% cost savings, 40–60% reduction in delays) continue to hold at scale, it will firmly establish that prior authorization need not impede care, and indeed can promote it.

Conclusion

Cohere Health has in a few short years transitioned from a startup with a novel idea into a leading provider of AI-powered utilization management solutions. By focusing on the patient-provider-plan alignment and leveraging clinical intelligence, Cohere has demonstrated that the historically contentious prior authorization process can be turned into a collaborative, efficient stride toward high-value care. With strong financial backing (over $200M raised), marquee clients and partnerships (Humana, Geisinger, MCG), and measurable performance gains documented in real-world deployments (^[5]) (^[6]), Cohere has effectively validated its model in the market.

Looking forward, Cohere is well-positioned to drive further innovation. The company continues to evolve its platform (e.g. expanding to new specialties, adding personalized workflows) and to anticipate regulatory/compliance requirements. Its clinician-led approach and early wins are likely to yield continued adoption, especially as health plans face pressure to streamline care and reduce administrative waste. Overall, Cohere Health appears to have successfully “cohered” the three stakeholders of healthcare into a more unified process – and in doing so, set a new standard for how AI and human expertise can jointly improve healthcare delivery (^[2]) (^[10]).

References: This report cites peer-reviewed journals and industry publications for facts and figures (e.g. AMA and ASCO surveys on PA burdens (^[11])), as well as analyst and news articles (Fierce Healthcare, Reuters, etc.) on funding and technology. Data on Cohere’s products come from its published press releases and whitepapers (^[8]) (^[24]). Industry recognitions (KLAS awards, Gartner listings) were confirmed from official sources (^[9]) (^[31]). All statistics and claims above are attributed to these sources.