Self-funded, Blues, or PBM. The model changes every time. So do we.
Each segment runs under different regulators and margin pressures. We build for the difference and not around 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
The back office is where health plan margins are won or lost
Admin waste, denial rates, and regulatory timelines are all compressing at the same time across every plan type.
Admin waste
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$21B
The medical industry could still save $21B a year by automating manual transactions. Most of it sits in claims, enrollment, and provider operations—the functions health plans run every day.
CAQH, 2025 Index, February 2026
Denial cost
50%
Missing or inaccurate data is the leading cause of claim denials, cited by 50% of revenue cycle leaders in 2025. Every denial is rework, delay, and provider friction that compounds across the book.
Experian Health, State of Claims Survey, 2025
Regulatory pressure
72 hours
From January 2026, CMS requires urgent prior authorization decisions within 72 hours and standard decisions within 7 calendar days, increasing turnaround pressure across claims, utilization management, and appeals.
CMS, Prior Authorization Final Rule CMS-0057-F, 2026
PROVEN OUTCOMES
What running core health plan operations actually produces
Claims, enrollment, appeals, and provider operations. Four results from four live programs.
$26M
in claims savings
A top-5 national health plan took claims as a service and received $26M in savings, underwritten in the commercial pricing and passed to the client.
66%
faster urgent appeals
A top-5 national health plan resolved 99.5% of urgent appeals within 4 hours, cutting turnaround by 66% using AI and ML triage at 99.99% accuracy.
80%
higher audit productivity
Provider audits moved from manual to fully automated for a top Blue plan, delivering above 99% accuracy across 230,000 provider files annually.
3X
exchange enrollment growth
A leading Blue plan launched a new exchange line and tripled enrollment within 6 months, ranking above incumbents on CMS acceptance testing.
CLIENT SPOTLIGHT
$200M in projected savings on a full-plan BPaaS transformation
How a leading Blue plan moved its entire back office onto a single PMPM model without a production outage.
The plan moved its entire back office onto a single PMPM model, cutting admin spend 20%, removing about half its tech debt across hundreds of applications, and completing 10-plus transformation projects in 24 months with no platform production outage caused.
20%
reduced spend
Who We Serve
Each segment runs on its own operating logic
National plans, Blues, self-funded, specialty, and PBMs each run under different regulators, margin structures, and operational logic. We build for the segment, not around it.
Every line. Every state. No simplification.
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 for the largest national books, on operating expertise.
- 66% faster urgent appeals
- $26M in claims savings
Modernization that keeps member operations running
Regional and Blues plans face local regulation and the cost of multi-platform administration. We deliver end-to-end BPaaS transformations across claims, enrollment, member services, and provider operations, cutting admin spend and tech debt without a platform production outage.
- $200M projected savings in 7 years
- 20% lower admin spend
- ~50% tech debt removed
- 3X exchange enrollment growth
Full claims risk demands full precision
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 on PMPM pricing, with multi-platform migration experience.
- 35-40% lower admin cost through BPaaS with global delivery
- Claims in all 50 states
- QNXT and HealthRules migration
Built for the plans where margins are thin
Dental benefit administrators run thin margins and heavy configuration. Vision benefit administrators need rolling benefit tracking, real-time accumulator data sharing, and benefit-limit enforcement across member, provider, and plan systems. We run profitable operations for both.
- Up to 99.4% dental accuracy
- 7M+ member dental BPaaS
- Real-time accumulator sharing (vision)
Transparency mandate met. M3P outreach live.
PBMs are navigating regulatory scrutiny, transparency mandates, and the shift from spread-pricing to administrative service fee models. We support PBM operations starting with the Medicare Prescription Payment Plan (M3P), delivering personalized, omnichannel enrollment outreach using psychographic segmentation and integrated action microsites.
CLIENT SPOTLIGHT
New market. New operating model. Faster than projected.
3X enrollment growth, on a Medicaid-to-Exchange BPaaS launch.
A California-based public health plan serving Medicaid and Duals members launched a new Covered California Exchange product. Firstsource delivered end-to-end BPaaS including EDI connectivity, enrollment, billing, claims, and broker platform. Launch completed ahead of schedule, with monthly reconciliation accuracy above 99.8%, ranking above incumbents on CalHEERS integration testing.
99.8%
reconciliation accuracy
PROVEN OUTCOMES
Health plan performance is built in the operating layer
Active engagements showing what happens when execution, accountability, and scale move together.
8 of 10
top US health plans
We run core operations for 8 of the top 10 US health plans across claims, enrollment, member services, and provider operations.
75M
claims processed
Manual claims processed in a year across the health plan portfolio, at 99.9% financial accuracy and over 99% adjudicated within 2 days.
45%
lower operating cost
BPaaS engagements deliver up to 45% reduction in operating cost, with technology migration funded from year-one savings and outcomes 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.
Contact Us
Every plan is different. The segment is where the model starts.
Segment and cost structure are where the operating model starts. The outcomes and what funds the technology migration go into the contract from day one.
- Operators running core operations for top US health plans.
- A segment-specific build, not a generic operating model.
- Priced on the outcome, with savings that fund the technology migration.