The cost of a claim isn’t the claim. It’s the second look.
Firstsource runs claims operations for top US health plans, priced on the leakage we remove, not the hours we bill.
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 claims P&L absorbs pressure from three directions at once
Manual touches, denial rates, and prior auth mandates are all compounding at the same time.
Admin waste
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$21B
The medical industry could still save $21B a year by automating manual transactions, much of it in claims. Manual touches are where claims cost compounds.
CAQH, 2025 CAQH Index, February 2026
Denials
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.
Experian Health, State of Claims Survey, 2025
Prior auth
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72 hours
From January 2026, the CMS prior authorization rule requires urgent decisions within 72 hours and standard within seven days, adding cost and turnaround pressure across claims and utilization management.
CMS, Prior Authorization Final Rule CMS-0057-F, 2026
PROVEN OUTCOMES
What agentic claims operations actually move
Live results from production claims operations across multiple US health plans.
30%
lower cost per claim
A multi-state Medicare and Medicaid plan cut cost per claim by 30% with agentic AI workflows across adjudication and adjustments.
$26M
estimated client claims savings
A leading multi-state Medicare and Medicaid plan achieved approximately $26M in estimated savings through AI-powered Claims as a Service, with financial structuring tied to business outcomes, not SLAs.
~90%
auto-adjudication
The Decision Agents platform auto-adjudicates approximately 90% of claims, holding 99.9% financial accuracy with 99% adjudicated within 2 days.
99.9%
financial accuracy
Across 20 health plan clients, claims financial accuracy holds at 99.9%, with payment accuracy at 99.6%.
CLAIMS OPTIMIZATION SOLUTIONS
Where the work runs, and where the agents already are
From intake to appeals, the agents are already running in production. Here is where each one sits.
Bad data stopped at the door
A digitized, AI-assisted intake layer validates, classifies, and routes claims before adjudication, capturing structured data from EDI, paper, portal, and fax at 99%-plus accuracy.
- Real-time eligibility and benefit validation
- Intelligent queue routing by risk
- Volume spikes absorbed, not queued
~90% auto-adjudication
The claims adjudication agent, live in production, applies rules and AI decision support across platforms, holding 99.9% financial accuracy with 99% of claims adjudicated within 2 days.
- Standing operating procedure copilot navigation and review
- 4,640+ examiners, AI-assisted
Errors caught before disbursement
The payment integrity agent enforces accuracy before payment, cross-referencing EOB, contract terms, and coordination of benefits in real time across $4B in monthly payments at 99.6% accuracy.
What slips through doesn't stay lost
A structured identification and recovery workflow surfaces overpayments and pursues them through provider outreach, offset, and demand letters, with process mining fixing root causes, not just chasing claims.
- Systematic identification, not sampling
- Closed-loop into adjudication rules
- Trackable, escalating workflows
- Recurring-pattern detection
Actual versus expected, at claim level
Agentic automation compares actual claim behavior against clinical evidence, contract terms, and coding rules to surface anomalies that pattern-matching misses, pre- and post-payment.
- Upcoding, unbundling, fictitious billing
- Provider outlier benchmarking
- NSA IDR-informed prioritization
- Structured investigation workflows
Target the highest-risk claims
A propensity model surfaces the highest-risk claims for focused review, combining signals, late-payment exposure, and clinical complexity, instead of blanket pend-and-review that drags turnaround.
- Configurable thresholds by LOB
- AI-assisted reviewer context
- Coding flags pre-loaded
- Lower handle time
- Consistent decisions
Resolved inside the CMS window
AI-assisted A&G intake, categorization, and routing, with pre-summarized case context for clinical reviewers, delivering a 66% turnaround reduction at 99.99% decision accuracy
- AI intake and routing
- 99.5% urgent within 4 hours
- Pre-summarized case context
WHO WE SERVE
Your line of business determines where leakage hides
Claims leakage sits in different places depending on your line of business. We find it in yours.
National plans
Leakage hides differently across every line
Hidden leakage across Medicare, Medicaid, Commercial, and Exchange lines differently. Firstsource surfaces it at the claim level across all four.
Blues plans
35% lower admin cost. Admin loss ratio back in range
Blues plans carry multi-platform admin cost on top of claims leakage. Firstsource cut admin spend 35% and brought the admin loss ratio back in range, without platform disruption.
Self-funded
Every adjudication error lands on the employer
Self-funded arrangements carry full claims risk. Firstsource runs claims on PMPM pricing at 99.9% financial accuracy, TPA-licensed across 36 states.
PROOF OF DELIVERY
Live claims programs, each proving a different result
Payment scale, manual effort reduction, and automation coverage. Each from a different live engagement.
$4B
monthly payments
Firstsource processes about $4B in payments a month at 99.6% payment accuracy across complex fee schedules and multi-payer coordination.
70%
less manual effort
NelsonHall independently cited a roughly 70% reduction in manual effort through AI-generated feedback loops in Firstsource claims operations.
30%
claims automated
A national plan's claims-as-a-service program automates 30% of claims processing across 20 states.
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
The leakage is in the data. Stop paying per hour for cost you can price per claim.
Per-claim pricing changes the incentive. What the four agents close first depends on where yours is escaping today.
- 4 claims agents, 2 live in production, no platform migration.
- Priced per claim with performance floors, not headcount.
- $40M in realized LPI savings for a top-5 plan