Medicare Advantage client achieved a 48% finding rate and <2% appeal rate by identifying errors in high-cost claims before payment

BOSTON, Nov. 4, 2026 /PRNewswire/ — Cohere Health^®, the leading clinical intelligence and operations platform for health plans, today announced that a Medicare Advantage client identified more than $10 million in savings in six months by finding complex clinical and coding errors in high-cost drug and durable medical equipment claims before payment.

The results were achieved through Cohere Health’s pre-pay clinical review program, which combines AI-powered claim selection, clinical and reimbursement expertise, and scalable review services built on the company’s clinical intelligence platform. The program delivered a 48% finding rate and an appeal rate below 2%.

Traditional payment integrity programs rely heavily on post-payment audits, a resource-intensive model that creates provider abrasion, drives appeals, and recovers dollars only after they’ve already been spent. At the same time, Medicare Advantage plans face tightening margins, surging specialty pharmacy costs, and growing provider pushback against opaque audit processes. Plans need a new way to improve payment accuracy without straining provider relationships.

“Modern payment accuracy should be about identifying the right claims early, supporting decisions with clear clinical evidence, and doing so without creating more burden for providers and health plan teams,” said Lalithya Yerramilli, SVP of payment solutions at Cohere Health. “That’s what transparent, clinically grounded review workflows make possible.”

Cohere Health’s approach shifts intervention earlier in the payment cycle. Its intelligent claim selection technology analyzes the full claims population, helping focus review resources on the claims most likely to contain errors, while allowing clean claims to move forward without unnecessary delay. Drawing on clinical evidence generated across the care-to-payment lifecycle, precision AI agents review medical records at scale and surface claims that warrant closer human review.

Every determination traces back to a clear, citable source–such as CMS rules, plan-specific policies, or contractual terms–giving providers specific rationale they can trust, understand, and act on.

Cohere Validate™ is Cohere Health’s AI-powered clinical and coding validation solution for scaling payment integrity operations with greater speed and precision. As part of the broader Cohere Unify™ platform, Cohere Validate helps connect the same clinical, operational, and financial context across the health plan enterprise–supporting the shift away from disconnected operations and AI point solutions toward proactive, transparent payment accuracy.

To read the full case study, visit https://www.coherehealth.com/case-study/how-prepay-audit-unlocked-10m-in-just-six-months.

About Cohere Health 
Cohere Health‘s clinical intelligence and operations platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With an enterprise approach that streamlines payer-provider decision-making across the care continuum–including policy, prior authorization, payment accuracy, and more–the company improves collaboration and reduces burden, resulting in up to 9x ROI and 94% provider satisfaction. Cohere Health is recognized on TIME’s World’s Top HealthTech Companies list, on the Inc. 5000 list, and by numerous industry analysts.

Media Contact
Brynn Spicher
anthonyBarnum Public Relations
brynn.spicher@anthonybarnum.com

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SOURCE Cohere Health