Intelligent Back Office for health plans that need proof, not pilots
We run claims, enrollment, and appeals for 8 of the top 10 US health plans in production, priced on what moves.
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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
Provider pressures impacting health plan operations
Rising labor costs, claim denials, and Medicaid policy changes are increasing friction between payers and providers.
RISING LABOR AND OPERATING COSTS
>$1T
Hospitals spent more than $1T in 2025 on workforce costs, while many continued operating on thin margins.
American Hospital Association (AHA), Costs of Caring, 2025
ESCALATING PAYER DENIALS
$43B
Hospitals spent $43B in 2025 trying to collect payments from insurers for care already delivered, including work to overturn claim denials and address prior auth issues.
American Hospital Association (AHA), Costs of Caring, 2025
MEDICAID REIMBURSEMENT PRESSURE
11.7%–13.3%
New Medicaid policy changes are projected to reduce hospital operating margins by 11.7%-13.3% on average in Medicaid expansion states.
The Commonwealth Fund, Impact of Medicaid Policy Changes on Hospital Revenues and Margins, 2025
PROVEN OUTCOMES
The pressure is real. So are the results.
Live outcomes from health plan operations — claims, enrollment, and process intelligence.
$5.2M+
annual claims savings
Claims adjudication was redesigned using Process Intelligence. ML-predictable adjustment propensity was identified, and the Business Rule Framework was reconfigured. This delivered $5.2M+ in annual savings and a 20% reduction in adjustment rates.
30%
total cost reduction
A LangGraph multi-agent workflow was deployed on QNXT, Facets, and Proclaim. It delivered a 30% cost reduction, an 80% reduction in error rates, and a 50% productivity improvement across approximately 80M active annual claims.
75M
claims processed
Running for 8 of the top 10 US health plans, Firstsource processes 75 million manual claims a year. The Digital Intake platform captures data from 220 million claims annually.
220M
claims data captured
Our Digital Intake Platform processes 220M claims with more than 99.6% critical field accuracy. It automates 85% of claims effort and maintains 100% TAT adherence.
DEEP DOMAIN SOLUTIONS
Six solutions. Each one targets where cost and risk sit.
From claims through member outreach, every function where a health plan leaks cost or accumulates risk.
CLAIMS
Claims, adjudicated and paid right
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
Enrollment without the leakage
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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ANALYTICS
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 $5M in late-payment interest recovered for a leading US healthcare payer.
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APPEALS
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 using AI and ML triage, at 99.99% decision accuracy inside the CMS window.
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CLIENT SPOTLIGHT
Claims adjudication rebuilt: $5.2M+ saved annually
A multi-state Medicare and Medicaid payer was experiencing high rates of claims adjustment and late payment penalties that could not be traced to a single root cause.
Standard process documentation described how adjudication was designed to run, not how it was actually running across 80M active claims.
Standard process documentation described how adjudication was designed to run, not how it was actually running across 80M active claims.
Firstsource deployed Process Mining across 2 years of event log data reconstructing the actual adjudication flow, identifying ML-predictable adjustment propensity, and reconfiguring the Business Rule Framework rules driving the highest-cost deviations. Annual savings of $5.2M+ with a 20% reduction in adjustment rates.
$5.2M+
annual savings
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.
NATIONAL PLANS
Medicare, Medicaid, Commercial, 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, no member disruption
Regional and Blues plans face local regulation and the cost of multi-platform administration. We deliver that cut admin spend by 35% to 40% and remove approximately 40% of tech debt across 225-plus applications.
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SELF-FUNDED
Self-funded precision, 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.
Specialty Plan
Dental claims, configured and accurate.
Dental benefit administrators run on thin margins and heavy configuration. We raised tier 1 dental claims accuracy from 95.6% to 99.4% and runs a dedicated dental BPaaS for a 7M-plus member book.
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PBMS
Transparency mandates met. Spread pricing behind you.
PBMs face transparency mandates and spread-pricing pressure. Firstsource runs BPaaS for PBM admin, claims, member services, and formulary administration, priced on consumption with accuracy and turnaround SLAs in the contract.
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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Most AI investment in health plans is sitting in proof of concept
We run production operations for 8 of the top 10 US health plans. Tell us your claims volume and biggest back-office friction point.
- Most health plan back-office problems are visible in the event log data before they show up in the adjustment report.
- The technology migration is funded from operating savings from year one, with no upfront CapEx.
- Priced on what moves: the savings and error rate reduction it delivers, not the headcount it takes.