AI Platform Turns Static Health Policies into Dynamic Digital Assets

BOSTON, MA – December 09, 2025 – In a move aimed at the digital transformation of one of healthcare's most entrenched administrative bottlenecks, clinical intelligence firm Cohere Health has launched Cohere Policy Studio™. The new solution leverages artificial intelligence to convert static, text-based medical policies into structured, interoperable digital assets, tackling a foundational problem that costs the U.S. healthcare system billions annually and places an immense burden on providers.

The announcement comes as health plans grapple with a perfect storm of challenges: soaring administrative costs, intense regulatory pressure for transparency, and deeply strained relationships with healthcare providers. By creating a single, automated source of truth for clinical policies, Cohere Health aims to provide an infrastructure layer that has been sorely missing in the industry's push toward automation and efficiency.

The Crushing Weight of Static Policies

For decades, medical policies—the complex rules that dictate coverage and care—have existed primarily as disconnected, hard-to-navigate PDF documents. This analog approach in a digital world is a primary driver of the administrative waste that accounts for an estimated 25% of total U.S. healthcare spending. The friction is most palpable in the prior authorization (PA) process, a system intended to ensure care is necessary and appropriate but which has become a major source of frustration and delay.

Industry data paints a stark picture of the consequences. The administrative costs tied directly to prior authorizations are estimated to be around $35 billion each year. For physicians on the front lines, the burden is staggering. Studies show that physicians and their staff spend, on average, 13 to 14 hours per week managing PA requests. This administrative slog is a leading contributor to burnout, with nearly 90% of physicians citing it as a significant factor.

The impact extends beyond the clinic's back office, directly affecting patient care. An overwhelming majority of physicians—over 90%—report that the cumbersome PA process leads to delays in necessary treatment. These delays are not benign; they can lead to patients abandoning their recommended course of care and, in the most severe cases, result in serious adverse health events.

A Regulatory Clock is Ticking

The launch of Policy Studio is timed to address a rapidly closing window for compliance. Health plans are facing mounting pressure from both federal regulators and industry coalitions to modernize their operations. The Centers for Medicare & Medicaid Services (CMS) has put a firm deadline on the table: a mandate for an electronic Prior Authorization (ePA) API by 2027 to streamline data exchange.

However, the industry is far from ready. Recent data from the Council for Affordable Quality Healthcare (CAQH) reveals a significant compliance gap, with only 35% of prior authorizations currently processed electronically. Even more concerning, a mere 9% of surveyed organizations can support the kind of API mandated by CMS. This disparity highlights the systemic challenge: true automation is impossible when the underlying policies are not digitized or structured for machine consumption.

Adding to the pressure is a landmark 2025 pledge from America's Health Insurance Plans (AHIP) and the nation's largest insurers. This commitment includes standardizing electronic prior authorization and reducing the overall scope of services that require it. Without a way to systematically manage, update, and communicate policies, meeting these goals becomes an operational nightmare. For health plan executives, regulatory pressure has become a top concern, with over half now investing in AI and machine learning specifically to automate approvals and avoid costly non-compliance penalties.

From PDFs to APIs: Digitizing Healthcare's Backbone

Cohere Policy Studio enters this environment by targeting the root cause of the problem: the unstructured policy document itself. The platform serves as a centralized hub for the entire policy lifecycle, using what the company calls "precision AI" to ingest and analyze unstructured documents like PDFs.

"Health plans are under tremendous pressure to modernize their policy management practices, but the infrastructure to do so simply didn't exist before," said Matt Parker, chief product officer at Cohere Health. "Cohere Policy Studio eliminates the technical complexity and manual burden of policy digitization, so a health plan's policies are automatically configured to support critical workstreams from interoperable authorization workflows to public transparency websites."

Behind the scenes, this process involves a sophisticated application of Natural Language Processing (NLP) and machine learning. The AI models are trained to read and understand complex medical language, extracting key elements such as covered services, medical necessity criteria, and relevant procedure codes. This structured data is then converted into API-ready files and automated approval rules. The result is a dynamic, single source of truth that can power a health plan's entire utilization management ecosystem, from public-facing policy websites to the backend logic that auto-approves up to 90% of requests for millions of members, as Cohere Health's existing platform already does.

By connecting all policy-dependent functions to one central, digitized repository, the solution is designed to minimize the policy "drift" that often occurs between departments, a common source of compliance vulnerabilities and provider confusion.

Mending the Payer-Provider Divide

Beyond compliance and internal efficiency, the broader promise of this technology lies in its potential to heal the fractured relationship between payers and providers. By creating a transparent, consistent, and automated framework for medical policies, solutions like Policy Studio could fundamentally change the dynamic of their interactions.

For providers, the benefits are clear. A system that offers real-time, automated feedback on prior authorization requests based on clear, accessible policies could dramatically reduce administrative workloads. Research on early ePA initiatives has already shown a 69% reduction in decision wait times. Further automation promises to return precious hours to clinical staff, allowing them to focus on patient care instead of paperwork and phone calls.

This shift fosters a greater sense of trust and transparency. When rules are applied consistently and the rationale for decisions is clear, the perception of arbitrary denials diminishes. Providers can better understand what is required for an approval, leading to fewer initial rejections and a less contentious appeals process. Ultimately, this efficiency translates into faster, more consistent access to care for patients, mitigating the risks of treatment delays and abandonment.

As the healthcare industry continues its slow but inevitable march toward interoperability and value-based care, the digitization of foundational assets like medical policies is no longer an option, but a necessity. Innovations that transform these static documents into dynamic intelligence are critical for building a more collaborative, efficient, and patient-centric healthcare supply chain.