June 15, 2023

Revolutionizing Prior Authorization Workflow: Banjo Health's Generative AI Transforms PA Processes for Health Insurers and Pharmacy Benefit Managers

Traditional prior authorization workflows are complex and time-consuming, leading to delays in care. Banjo Health, a leading health tech company, has introduced Composer and CARE, powered by large language model (LLM) based natural language processing (NLP), to dramatically improve the prior authorization workflow process for health insurers and pharmacy benefit managers (PBMs). In this blog post, we will explore how Banjo Health's proprietary AI technology is transforming the landscape, enhancing efficiency, and optimizing patient outcomes.


Streamlining the Prior Authorization Workflow with Composer and CARE:


  1. Composer: Simplifying Criteria Transformation

Banjo Health's Composer utilizes a variety of patented AI models to streamline the transformation of clinical criteria documents into formatted and programmable clinical decision trees. Composer uses LLM powered span recognition to recognize the logical units or clauses within criteria documents. It then uses Generative AI to transform the sentences found in the clinical criteria into questions that clinical reviewers will see during review. This ensures accurate interpretation and enables the generation of relevant questions for clinical reviewers. With Composer, health insurers and PBMs can automate and expedite the transformation of complex clinical criteria into actionable decision trees, significantly reducing administrative burden and accelerating the prior authorization workflow up to 95%.


  1. CARE: Optimizing Clinical Reviews with AI

Banjo Health's CARE engine revolutionizes clinical reviews by harnessing the capabilities of AI. Through optical character recognition (OCR) and NLP technologies, CARE prepopulates set fields during case creation, reducing manual data entry efforts for insurers and PBMs. LLMs are used as the basis of information retrieval models to find the most pertinent evidence for each question within the clinical decision tree. Additionally, LLM based question answering models are then used to pre-answer all the questions within the decision tree and provide a recommended determination. This intelligent approach ensures that clinical reviewers navigate the shortest path to accurate decisions, saving time and improving overall workflow efficiency. By leveraging AI to find relevant evidence within attached patient documents, CARE empowers reviewers to make informed decisions backed by comprehensive information.


Enhancing Efficiency and Improving Outcomes:


  1. Drastic Reduction in Administrative Burden

Banjo Health's Generative AI technology drastically reduces the administrative burden associated with prior authorization workflows. By automating the transformation of clinical criteria, Composer allows payers and PBMs to quickly convert their clinical criteria documents into decision trees that are much easier to navigate during clinical review.  The OCR + NLP process involved in CARE allows users to spend less time on data entry and case creation.  


  1. Expedited Prior Authorization Process

CARE expedites the prior authorization process by simplifying and optimizing clinical reviews. The pre-answered questions and evidence analysis capabilities of CARE provide clinical reviewers with valuable insights, facilitating faster decision-making. This efficiency translates into reduced wait times for patients, ensuring timely access to necessary treatments and improving overall patient outcomes.


  1. Continuous Improvement through AI Feedback Loop

Banjo Health's commitment to continuous improvement is evident through the feedback loop integrated into their generative AI models. By capturing feedback from clinical reviewers during the review process, the models continuously evolve and refine their decision-making capabilities. This iterative process enhances accuracy, reduces errors, and further streamlines the prior authorization workflow.


Banjo Health's Composer and CARE, powered by AI, revolutionize the prior authorization workflow for health insurers and PBMs. Through the transformation of clinical criteria into programmable decision trees, pre-answered questions, and AI-driven evidence analysis, Banjo Health optimizes efficiency and improves patient outcomes. By leveraging Banjo’s AI, insurers and PBMs can streamline administrative processes, expedite the prior authorization workflow, and provide timely access to the most appropriate treatments for patients. Banjo Health's commitment to continuous improvement ensures that their AI-powered solutions evolve and adapt to the ever-changing healthcare landscape, driving better outcomes for all stakeholders involved in the prior authorization process.