COHERE HEALTH

Nikhil Garg spent over a decade in healthcare technology, including time at McKinsey and health plan companies, watching the same broken process destroy patient care from the inside. Prior authorization — where insurers require pre-approval before covering treatments — was designed as a cost control tool but had mutated into a bureaucratic nightmare.

Doctors spent 16 hours per week on prior auth paperwork. Patients waited weeks for approvals while their conditions worsened.

Insurance companies employed armies of nurses just to review faxed forms. Garg co-founded Cohere Health in 2019 with the thesis that AI could replace the fax-and-phone-call process with intelligent, evidence-based instant decisions.

Not removing prior auth entirely — insurers won't give that up — but making it fast enough that it stops hurting patients.

B2B SaaS sold to health insurance plans. Cohere Health replaces the legacy prior authorization workflow with an AI-powered platform.

Insurance companies pay for the software on a per-member-per-month basis. When a doctor submits a prior auth request, Cohere's AI reviews clinical guidelines, patient history, and evidence-based criteria to make an approval or denial recommendation — often in minutes instead of days.

The platform handles the full cycle: submission, clinical review, decision, and appeals. Revenue scales with the number of insured lives the health plan manages.

Cohere Unify — single platform that consolidates prior auth, utilization management, and care navigation into one system. AI-powered clinical review engine that reads medical records and matches them against evidence-based guidelines automatically.

Real-time decision support that gives providers instant feedback on whether a request will likely be approved. Provider portal that eliminates phone calls and faxes — doctors submit digitally and get decisions digitally.

Analytics dashboard showing approval rates, turnaround times, and cost impact for health plan executives. Interoperability layer that connects with existing EHR systems and health plan infrastructure.

Selling directly to health insurance plans — these are massive enterprise deals with long sales cycles but enormous contract values. Each health plan covers millions of members, so a single client represents huge revenue.

Cohere positioned itself as the solution to CMS regulatory pressure — the Centers for Medicare & Medicaid Services issued rules requiring faster prior auth decisions, and health plans needed technology to comply. Strategic partnerships with existing health IT vendors to integrate into workflows rather than replace them.

Conference presence at AHIP and HIMSS where every health plan executive shops for technology.

Enterprise sales cycles in healthcare insurance are brutally long — 12 to 24 months from first meeting to signed contract. Health plans are conservative buyers who need extensive pilot data before committing.

Integration with legacy systems that were built in the 1990s and still run on COBOL is a real technical challenge. The regulatory environment keeps shifting — CMS rules on prior auth keep changing, which is both an opportunity and a compliance headache.

Competition from established players like EviCore and New Century Health who have decades of relationships with health plans. And the fundamental political risk: if prior auth gets legislated away entirely, the core use case shrinks dramatically.

Investors include Andreessen Horowitz (a16z), Deerfield Management, Flare Capital Partners, and Longitude Capital. Series B in 2022 brought total funding past $100 million.