Cohere Health Introduces First Configurable Sepsis Audit Agent to Power Smarter Payment Integrity

Agentic AI solution adapts to five unique policy frameworks, autonomously closes no-finding claims, and drives optimized savings for health plans

BOSTON, Nov. 18, 2025 /PRNewswire/ -- Cohere Health^®, the leader in clinical intelligence solutions for health plans, announced the launch of its Sepsis Audit Agent, the first configurable agentic AI solution for sepsis clinical and coding validation. Cohere Health's new flexible audit agent advances the industry beyond outdated one-size-fits-all sepsis auditing.

Early adopter health plans are already achieving $4k-$5k in average savings per claim with a 58% findings rate, with the agentic technology matching the throughput of 2-3 full-time auditors, thereby allowing the organization to expand overall audit capacity for other areas.

Sepsis remains one of the most complex and costly conditions to audit, and a leading source of payment disputes. Based on Cohere Health's customer analysis, 56% of Medicare audits and up to 9% of inpatient spend for an average Medicare Advantage plan can be attributed to sepsis. Sepsis diagnoses are themselves nuanced, as multiple competing clinical frameworks create confusion and friction between health insurance plans and providers.

The Sepsis Audit Agent, part of the Cohere Validate™ payment integrity solution, is designed to address these longstanding challenges by combining clinical intelligence, agentic AI automation, flexible policy configuration, and integrated workflows.

"The Sepsis Audit Agent reflects our focus on clinical intelligence: AI that truly adapts to your unique policies," said Siva Namasivayam, CEO and co-founder of Cohere Health. "Similar to how we led the industry transformation of prior automation, Cohere Health is now reimagining payment integrity. Auditable agentic AI offers both policy control and automation by delivering transparency, efficiency, and the ability to bring high-value sepsis audits in-house with confidence."

The Sepsis Audit Agent adapts to each health plan's unique sepsis criteria across five distinct policy frameworks, supporting policy alignment and consistency. Operating autonomously, the Agent scans medical records, calculates clinical scores (including SOFA, qSOFA, and SIRS), validates diagnoses, and automatically closes no-finding cases. Auditors receive thoroughly reviewed and prioritized cases that require their expertise, rather than having to do the initial screenings. Additionally, the platform integrates grouper and pricer functionality to automatically assign DRGs and calculate reimbursement amounts, with complete evidence linking.

"Health plans no longer need to settle for conventional AI-assisted auditing–this is AI-driven auditing with human oversight," added Lalithya Yerramilli, SVP of payment solutions at Cohere Health. "The Agent fundamentally modernizes workflows, handling the most time-consuming aspects of sepsis validation, and auditors reclaim time to focus on cases with inaccurate billing while maintaining superior clinical accuracy."

From recovery to prevention
By connecting pre-service authorization data with post-service clinical validation, Cohere Health has created a transparent ecosystem that identifies coding and clinical issues before payment instead of months later during retrospective audits. This helps to ultimately reduce disputes and strengthen payer-provider partnerships.

For more information about the Sepsis Audit Agent or to request a demonstration, visit coherehealth.com/payment-integrity/sepsis.

About Cohere Health
Cohere Health is the leader in clinical intelligence solutions, connecting health plans and providers to optimize utilization management and payment integrity. The company's AI-powered platform delivers real-time clinical decision support, transparent prior authorization workflows, and advanced payment integrity capabilities that improve care access, reduce administrative burden, and ensure payment accuracy.

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Brynn Spicher
anthonyBarnum Public Relations
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SOURCE Cohere Health