Health plans share the pressure. Not the operating model.
We run claims, enrollment, appeals and member engagement for 8 of the top 10 US health plans, each model designed for the plan behind it.
12 of Top 15
US health plans
3 of Top 5
Blue (BCBS) plans
100M
lives touched across the value chain
Avasant RadarView™
Leader in Healthcare Payer Business Process Transformation
Everest Group PEAK Matrix®
Leader in Healthcare Payer Intelligent Operations
NelsonHall NEAT
Leader in Healthcare Payer Agility & Innovation
Everest Group
Front-runner in the Generative AI Healthcare Payer Market
NelsonHall
Leader in Healthcare Payer Operational Transformation
ISG Provider Lens™
Leader in Payer Transformation on Healthcare Digital Services
Everest Group PEAK Matrix®
Leader in Healthcare Payer Business Process as a Service Solutions (BPaaS)
WHY THIS MATTERS
Cost, Stars, and deadlines are all moving against plans
Stars pressure, margin squeeze, and regulatory deadlines all land in the same place—the back office.
Medicaid squeeze
91%
Average Medicaid managed care medical loss ratio hit 91% in 2024, the highest in a decade and up from 88% a year earlier.
KFF, Health Insurer Financial Performance in 2024
AUTOMATION GAP
$21B
Despite record automation investment, the medical industry still has $21B in annual savings locked in manual and partially manual transactions.
CAQH Index 2025, February 2026
Market shift
~28B
The US payer back-office operations market reached $26B to $28B in 2025, growing 5% to 6% a year.
Everest Group, PEAK Matrix Assessment, 2026
Prior auth
72 hours
Under the CMS prior authorization final rule (CMS-0057-F), plans must return urgent decisions within 72 hours and standard decisions within 7 days. The mandate is in effect. Miss the window and it shows up in Stars.
CMS, Interoperability and Prior Authorization Final Rule, effective January 2026
Quality bonus
$12.7B
Medicare Advantage quality bonus payments reached $12.7B in 2025. Plans that miss 4 Stars watch that revenue shift to competitors.
KFF, Medicare Advantage Quality Bonus Payments, 2025
Cost pressure
52%
52% of health plan leaders name managing rising costs as their top challenge, for the second year running.
HealthEdge, 2026 Annual Payer Report
PROVEN OUTCOMES
A harder market is met with stronger plan operations
Real outcomes from live health plan programs. Not projected benchmarks.
$4.3M
realized in member outreach
Personalized omnichannel outreach helped convert missed appointments into rescheduled visits across a major health plan network. The program delivered $4M in annual value through increased revenue, reduced operating costs, and stronger member engagement.
35%
cut from core admin cost
Firstsource assumed end-to-end administration and streamlined core operations through automation and process redesign. The program reduced administrative costs by 35% while improving efficiency, governance, and overall operating performance.
3X
increase on enrollment growth
A large state health plan launched a new exchange product during Medicaid redetermination and achieved threefold enrollment growth. Reconciliation accuracy exceeded 99.8%, enabling rapid expansion while maintaining compliance and operational control.
66%
urgent appeals turnaround reduction
AI and ML triage reduced urgent appeals turnaround by 66% for a top-5 national health plan, bringing decisions from 12 hours to 4 hours, with 99.5% of appeals resolved within that window. The program now runs triage across 15-plus appeal types inside the plan's existing CMS compliance structure.
DEEP DOMAIN SOLUTIONS
Built around where cost and risk actually sit
Each solution targets where cost and risk sit on a health plan's book. Use one or run the whole operation.
Claims, adjudicated and paid right, every time
Most plans run 15% to 20% of claims through manual review. Firstsource raises auto-adjudication rates, reduces denials at the source, and holds 99.9% financial accuracy across government and commercial lines.
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Enrollment without the leakage, at every step
Backlogs at enrollment mean members start without benefits confirmed. Firstsource clears queues, reconciles eligibility, and handles exchange and government-line complexity at 99.5% CMS acceptance rate.
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Health plan data that predicts what is next
Most denial and late-payment risks surface in the data before they hit the book. Process mining and ML models flag them early, with $40M in late-payment interest recovered at a top-5 plan.
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Appeals that protect Stars
A missed appeals deadline costs Stars points, not just a grievance. Firstsource cuts urgent turnaround from 12 hours to 4 hours, with 99.5% of appeals resolved within that window at 99.99% accuracy.
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Provider data you can trust
Bad provider data is a denial before it happens. Firstsource runs credentialing, demographic updates, and directory accuracy at sub-15-day turnaround and 100% audit accuracy across 230,000 files a year.
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Effective member outreach
Generic outreach doesn't move hard-to-reach populations. We build psychographic-segmented, multilingual programs that drive HRA completion, care-gap closure, and scaled visit adherence.
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CLIENT SPOTLIGHT
Projected $200M in savings on a full plan rebuild
Replacing an administrator and modernizing a platform usually means disruption. This one didn't.
A leading Blue plan needed to replace its incumbent administrator and modernize an aging platform without disrupting members. Firstsource took over core admin operations on a PMPM model, drawing on multi-platform migration experience across QNXT and HealthRules, rationalized more than 225 applications, and completed 10-plus transformation projects in 24 months. The 7-year savings projection is $200M.
10+
transformation projects
WHO WE SERVE
No two plan types run the same way. We build for each one.
Each plan type runs under its own regulators, margin pressures, and operating logic. Generic models fail here.
National plans
Medicare, Medicaid, Commercial, and Exchange
National plans carry multi-state, multi-line complexity across Medicare, Medicaid, Commercial, and Exchange. We run claims, member and provider services, enrollment, and appeals at scale.
Blues plans
Blues modernization with no member disruption
Regional and Blues plans face local regulation and multi-platform administration costs. We deliver BPaaS transformations that cut admin spend 20%, eliminate half of tech debt, and deliver 9-figure savings.
Self-funded
Self-funded precision and predictable cost
Self-funded employers, TPAs, and ASO arrangements carry the full claims risk, so precision and predictable cost per transaction matter most. We run core admin, with multi-platform migration experience.
CUSTOMER STORY
Delivered $26M in guaranteed savings for a top-5 national plan
Moving claims operations to global delivery raised accuracy and member satisfaction at the same time as it lowered cost.
A top-5 national health plan running Medicare, Medicaid, and Marketplace lines across 20 states engaged Firstsource to build claims as a service: agentic workflows, copilots for top claim pends, and process mining across more than 100 million claims. Auto-adjudication now runs at ~90% with 99.9% financial accuracy, and the program has delivered $26M in savings on terms tied to the result.
How We Deliver
Unlock the operating system that compounds health plan intelligence
Discover Kairos, the operating system that turns health plan domain knowledge into a durable, compounding asset for claims, enrollment, and member operations, with 25+ years of health plan data baked in.
Transform
Rethink your health plan operating model, the workforce, and the commercial construct. Built for AI-native claims and member operations, not bolted onto the existing back-office playbook.
Implement
The intelligence must be built into claims workflows and health plan systems. Decisioning engines and agentic workflows are wired into production operations across claims, enrollment, and appeals.
Operate
We underwrite and own the outcomes. A human-plus-AI workforce stands behind the numbers, getting smarter with every claim, appeal, and member interaction.
TECH ENABLED
The technology ecosystem that ensures you own the intelligence
Every stage of the health plan operation is powered by copilots, decisioning engines, a domain harness, and autonomous agents, so the intelligence compounds inside your operation, not ours.
Domain harness engineering
The judgment, from day one
Agents running on our platform arrive pre-trained on 25 years of adjudication, UM, and FWA decisions.
The model itself
The models
The vision-language and domain models behind intake and adjudication. We build, fine-tune, and evaluate them as your data services partner.
CLIENT SPOTLIGHT
A dental plan ran leaner, and members felt the benefit
Moving dental operations to global delivery raised accuracy and member satisfaction at the same time as it lowered cost.
A California-based administrator of dental benefits to health plans, Medicaid, and Medicare programs wanted to globalize delivery and add automation across claims and contact center work for a multi-million member book. Firstsource runs the operation across the globe with GenAI training copilots speeding time to competence. Cost is down 20% over the contract term, and member CSAT improved by ~37%.
20%
cost reduction
RECOGNITION & AWARDS
Consistent performance wins recognition
Avasant RadarView™
Leader in Healthcare Payer Business Process Transformation
Everest Group PEAK Matrix®
Leader in Healthcare Payer Intelligent Operations
NelsonHall Neat
Leader in Healthcare Payer Agility & Innovation
Everest Group
Front-runner in the Generative AI Healthcare Payer Market
NelsonHall
Leader in Healthcare Payer Operational Transformation
ISG Provider Lens™
Leader in Payer Transformation on Healthcare Digital Services
Everest Group PEAK Matrix®
Leader in Healthcare Payer Business Process as a Service Solutions (BPaaS)
How we run it
Four things we refuse to trade off
Outcomes, compliance, intelligence, and cost accountability. Every program is built on all four.
Operating layer
Intelligence before impact
Every engagement runs on Kairos OS. Process mining identifies friction early. Predictive AI sets the order of work.
Built-in compliance
Compliance built in
CMS, HIPAA, HITRUST, TCPA, and state rules sit inside the workflow. We enable compliant claims delivery across all 50 states.
Commercial model
Savings fund the migration
We get paid when you save. No upfront capital bill: the technology migration is funded from operating savings from year one.
Scale
75 million claims a year
We run operations for 8 of the top 10 US health plans, process 75 million manual claims a year, and capture 220 million claims of data annually.
Capabilities we offer
These capabilities run under every health plan engagement
Solutions cover the what. These are the how behind every health plan program.
Every contact, faster and more accurate
Every contact handled faster and more accurately - member services, provider services, and broker support across Medicare, Medicaid, Commercial, Marketplace, and dual-eligible populations, with real-time AI assist built into every agent workflow.
Strategy that moves Stars and margin
We offer consulting and advisory built around the events that decide health plan outcomes: Stars and HEDIS, AEP and OEP readiness, Medicaid redetermination, and operating model redesign. Engagements open with a process-mining diagnostic of the real operation, not interviews, and run to a roadmap tied to the CMS calendar.
Built to run in your environment
We provide architecture, AI agent construction, and core system integration, from CCaaS implementation through production, governed by a progressive trust framework that moves from supervised to autonomous on a governed and regulated stack. Decision agents have cut provider contract turnaround by up to a 90% reduction.
The data backbone under every LLM
We deliver GenAI data services required to make agents and LLMs function within real operations: not using synthetic data, but validated, verified data that works in real operations, takes nuances into consideration, and compounds intelligence you can own.
Proof of Delivery
Live programs across plans, each proving a different result
Productivity, scale, and cost savings from distinct live engagements.
80%
productivity gain
Provider audits for a regional Blue plan moved from manual to fully automated, lifting productivity 80% at above 99% audit accuracy across 230,000 files annually.
75M
claims a year
Across 20 health plan clients, Firstsource processes 75 million manual claims a year at 99.9% financial accuracy, with 30% adjudicated straight-through by bots.
45%
lower operating cost
A mid-size regional Medicare and Medicaid plan ran appeals through a communication hub, cutting operating cost 45%.
WHY FIRSTSOURCE WINS
Where generic models fail, these engagements didn't
The shortcuts most health plan operations reach for, and what changes when the work is AI-native and outcome-priced.
WHAT TEAMS TRY
WHY IT FALLS SHORT
WHAT CHANGES WITH FIRSTSOURCE
Add offshore headcount
Cost scales with volume and quality drifts as the book grows.
Agentic workflows hold 99.9% financial accuracy while claims cost drops up to 30%.
Bolt AI onto legacy platforms
Point tools sit beside the work and do not touch the workflow.
Kairos OS runs process mining and predictive prioritization inside the workflow, so operations improve without added heads.
Lift-and-shift to a new platform
Full rebuilds stall and put member service at risk.
Multi-platform migration experience across QNXT and HealthRules; one Blue plan rationalized 225-plus apps with no production outage.
Sample one to two percent for QA
Errors and compliance gaps surface only after the fact.
Compliance sits in the workflow, with CMS and state mandate tracking built in.
TRUST & COMPLIANCE
Built for HIPAA, CMS, and state mandates
Designed to operate inside the most regulated health plan data environment in the US, not around it.
Regulatory frameworks
HEDIS and Stars measure tracking
CMS Interoperability and Prior Authorization Final Rule, CMS-0057-F
HIPAA and HITECH
TCPA, member outreach
NCQA credentialing standards
CMS Medicare Advantage quality and Stars
Certifications
HITRUST
SOC 2 Type II
ISO 27001
PCI DSS
SSAE 18
ISO 9001
INSIGHTS
Latest from the Firstsource team
Insights from the field, real operations, real outcomes, and perspectives from the people making it work in live operations.
Case Study
Building a strong foundation for growth: how a leading dental plan transformed operations with strategic partnership
Discover how a leading dental plan partnered with Firstsource to transform operations, reduce costs, improve CSAT, and enable scalable growth through AI and a hybrid delivery model.
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Find the cost hidden in your claims operations
The cost you cannot see is usually in the gaps between your workflows. That is where the operating model starts.
- Operators who run core operations for 8 of the top 10 US health plans.
- Built around your segment and line-of-business mix, not a generic model.
- Priced on the outcome, with savings that fund the technology migration.