Rating declines show up in your margins
Stop paying for advice. Let's talk consulting that commits to outcomes.
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
What's straining payer operating margins
Three structural forces every health plan leader is navigating.
STARS BONUS AT STAKE
$12.7B+
At least $12.7B estimated in MA quality bonus payments for 2025, based on the 2026 Star Ratings cycle. Only 40% of contracts reached the 4-Star threshold.
KFF, September 2025 + CMS 2026 Star Ratings
MEDICAID UNWINDING
25M+
Medicaid members disenrolled during post-pandemic unwinding, 70% for procedural reasons, with states facing a compliance deadline of December 31, 2026.
KFF, August 2025 + GAO-25-107413, June 2025
ADMIN COST REDUCTION
30%-40%
admin cost reduction achievable for health plans moving to integrated platform-based delivery, according to an analysis of BPaaS operating models.
HealthEdge BPaaS Report, March 2025
PROVEN OUTCOMES
Numbers from live payer engagements
Real outcomes from healthcare payer clients, not projected benchmarks.
$26M
in estimated claims savings for a multi-state Medicare and Medicaid plan, delivered under a claims-as-a-service model with outcomes underwritten.
99.5%
of urgent appeals resolved within 4 hours for a national health plan, running triage across appeal types at 99.99% accuracy.
45%
operating cost reduction for a regional Medicare and Medicaid plan, delivered through our Health Plan Communication Hub for prior authorization.
DEEP DOMAIN SOLUTIONS
Consulting built for the health plan
Every solution is designed to convert from advice into an outcome your operation actually feels.
Member experience transformation
We redesign enrollment, claims, and care navigation journeys so members stay engaged and avoidable contact volume drops, with Medicaid redetermination playbooks deployable in 45 days.
Learn more about how we transform member experience
Workflow and process re-imagination
We reimagine adjudication, prior authorization, member services, and AEP and OEP readiness for AI, through process mining-led diagnostics and an automation roadmap, so unit costs fall.
Learn more about how we approach process and workflow redesigns
Target operating model redesign
We define how a health plan runs claims, member services, and provider operations in AI-native ways, with delivery optimized across onshore and global operations, staying through full deployment rather than the strategy stage alone.
Learn more about how we rethink operating models
CLIENT SPOTLIGHT
For a top-5 national health plan, we cut urgent appeals TAT from 12 hours to 4 hours
A top-5 national health plan engaged Firstsource to transform appeals and grievances operations. Our AI intake and claims management platform triages across appeal types, reducing TAT by 66%. We resolved 99.5% of urgent appeals at 99.99% accuracy.
99.99%
appeals accuracy
How We Deliver Value
Transform, implement, operate: one continuous motion
Select a phase to see how it works for health plans.
Diagnose the real state of your payer operations before committing to a direction
Map claims, member services, and provider operations end-to-end, benchmark performance, and show leaders where cost, MLR, and member experience erode.
Discover AI-native payer diagnostic
- Auto-adjudication readiness scored against peer health plan benchmarks
- AI readiness assessed across people, process, systems, and governance
Design and build the operation your diagnostic said was possible
Design the future-state payer operation across claims and member services with a business case finance and compliance can defend.
Define requirements and business case
- Future-state requirements built from diagnostic findings
- Prioritized initiative roadmap with sequencing logic across claims, member services, and prior authorization
- Business case with return on investment model
- Success metrics tied directly to member satisfaction, auto-adjudication rate, and administrative cost
Design claims and member experience
- Experience design across the full member journey
- Claims workflow and technology architecture
- Phased implementation plan with milestones
Deliver the outcomes the business case promised
Run the payer operation we designed, holding MLR, adjustment, and member satisfaction gains long after the engagement officially closes.
Deploy lead, land, and run
- Change and adoption management across claims, member services, and prior authorization teams
- Claims adjustment rate and member satisfaction tracked and reported
- Steady-state operations for claims and member services
TESTIMONIALS
Firstsource CX strategy deliverable was super comprehensive and thorough, one of the best I have seen.
What Firstsource Consulting provides is a team of experts who can be real partners with us in driving innovation.
Firstsource's consulting deliverable is at par, if not better, than any Big 4 consulting company deliverable.
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.
Contact US
Start with discovery
- Rapid diagnostics: AI maturity mapped across your operations.
- Expedited benchmarking: Your position versus vertical peers.
- Fast-tracked roadmap: Where Kairos creates the most value, first.