John Brown
Member
Cohere Health has released new performance results showing how its Cohere Capture clinical evidence extraction engine can help health plans identify and close hidden HEDIS care gaps. The AI-powered solution analyzes existing clinical data to uncover missed opportunities, helping Medicare Advantage plans improve quality performance without adding significant administrative work. The approach strengthens health plan quality management by connecting clinical evidence with HEDIS workflows.
AI Helps Uncover Missed HEDIS Opportunities
Health plans often have valuable clinical information stored across multiple systems and formats. Important evidence may exist in prior authorization notes, imaging reports, electronic health records, and other clinical documentation without reaching quality teams in time.Cohere Capture is designed to analyze this structured and unstructured information and identify evidence that can support HEDIS care-gap closure. The technology also identifies denominator exclusions, helping plans distinguish between patients who still need care and those who should appropriately be excluded from a quality measure.
According to Cohere Health, clients using the solution have closed one in four high-value care gaps. The company also reports an average 15% improvement in Stars performance per measure, 107 gaps closed for every 1,000 members with records, and a minimum 5:1 return on investment through its performance-based model.
Turning Existing Clinical Data Into Quality Insights
Cohere Capture operates on the Cohere Unify clinical intelligence platform. The platform brings together clinical information from different sources and applies AI models designed around healthcare quality-measure logic.Rather than requiring health plans to collect entirely new information, the solution can work with clinical data that organizations already possess. For existing Cohere Health utilization management customers, this creates additional opportunities to identify care-gap closures from data already flowing through the Unify platform.
The system routes identified findings into health plans' HEDIS systems and links each finding back to the underlying source documentation. This creates a traceable evidence trail that can support review and validation.
Cohere Health also provides a clinical AI assistant to support human reviewers. This approach combines automated evidence extraction with human oversight rather than removing clinicians and quality professionals from the review process.
Reducing Dependence on Seasonal Chart Reviews
Traditional quality programs can require teams to conduct extensive chart reviews to find evidence needed to close care gaps. This process can consume considerable clinical and administrative resources, particularly when relevant information is buried inside unstructured records.Cohere Health is positioning Cohere Capture as a way to move toward a more continuous approach to quality management. Its broader Cohere Unify platform supports year-round evaluation of clinical documentation against HEDIS and other quality measures. The company previously reported that its quality capabilities could improve Stars HEDIS performance by 10% to 20% per measure.
This model allows health plans to use clinical information closer to the point when it becomes available instead of relying exclusively on end-of-cycle reviews.
Supporting Medicare Advantage Star Ratings
HEDIS measures contribute to the broader quality landscape that health plans navigate, including Medicare Advantage Star Ratings. Higher quality performance can affect a plan's financial results and its ability to invest in member benefits and programs.Cohere Health said that moving from three to four Stars can represent approximately $57 million in additional CMS payments per 100,000 members. The company argues that identifying care-gap closures already present in a plan's data can create another avenue for improving quality performance.
The timing also comes as health plans continue to monitor changes in quality measurement. NCQA released its 2026 Health Plan Ratings on September 15, with ratings incorporating HEDIS and CAHPS measures along with other factors.
A Performance-Based Approach
Cohere Capture differences from traditional chart-review services through its commercial model. Instead of charging health plans for every chart reviewed, Cohere Health uses a performance-based approach tied to results.The model is designed to focus the system on actionable findings rather than processing large numbers of charts regardless of their potential value. Cohere Health says this approach has helped clients achieve a minimum 5:1 return on investment.
For organizations already using Cohere Health's utilization management technology, the solution can also leverage existing clinical information without requiring additional data integrations. This could make it easier for those health plans to extend existing clinical intelligence into quality operations.
Connecting Quality With Broader Health Plan Operations
The HEDIS capabilities form part of Cohere Health's broader strategy to connect clinical intelligence across health plan functions.In June 2026, the company expanded Cohere Unify into areas including appeals, care management, claims operations, and quality. Cohere Health describes the platform as a connected intelligence layer designed to share clinical context across traditionally separate workflows.
For quality teams, this connected approach can provide access to clinical evidence generated during other health plan processes. Instead of treating measurement as an isolated activity, quality organizations can use information gathered during utilization management and other workflows to identify additional opportunities.
This strategy also reflects a broader shift toward using AI to process complex healthcare information while maintaining human oversight for important clinical and operational decisions.
Cohere Capture Available to Medicare Advantage Plans
Cohere Capture is currently available to Medicare Advantage health plans. Cohere Health is offering interested organizations a no-cost proof of concept that allows them to evaluate the technology using their own gap lists and clinical datasets.By combining AI-based evidence extraction, existing clinical data, HEDIS-specific logic, and performance-based pricing, Cohere Health aims to help health plans uncover quality opportunities that may otherwise remain hidden in their records.
As health plans continue moving toward more continuous quality measurement, technologies that can identify relevant evidence throughout the year could play a larger role in quality operations, Star Ratings programs, and member-care initiatives.
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