Healthcare · Prior Authorization
F20 Healthcare Payor
Re-architecting a decisioning system to accelerate the prior authorization approval process for a F20 health insurer
Impact
Deployed in 1 quarter
$200M+
Estimated cost savings
200k+
Cases per month with accelerated approval
90%+
Decisioning accuracy
The challenge
Insurers require prior authorization (PA) on certain procedures and prescriptions. Humans review these requests and compare them against evidence-based clinical policies. This review process is often manual, expensive, and time-consuming, creating significant compliance risks and making it difficult to standardize quality at scale.
The solution
Distyl built a decisioning system to review requests and their associated medical record data, compare them against clinical policies, and reason about them to make a decision, either approve the request or escalate for human review. The platform empowers clinical SMEs to directly refine AI logic using natural language, creating a robust, transparent audit trail.
AI capabilities
- 01
Policy-driven, consistent decisioning
Cross-source (e.g., multiple databases) document assessment. High accuracy / predictability in next-best-action suggestion
- 02
Intelligent case-routing
Scenario / case triage closely reflecting SME judgment calls
- 03
Auditable decisioning
Regulations-compliant automation enabled by LLM writing down its own step-by-step logic (vs. only the result) & source citations. Scenario triage reflecting SME judgment