Sorry, you need to enable JavaScript to visit this website.
Skip to main content

Leading health plan saves $25M, slashes costs up to 30% with AI and Claims as a Service


The challenge

Accelerate delivery of aggressive cost savings with AI

Firstsource had a long-time relationship with the client, a national leader in government health plans delivering services across the health plan value chain. This heavily regulated line of business had constrained our client from popular cost savings measures, such as using offshore resources. It had invested in a variety of robotic process automation solutions but was finding these had reached the limits of their utility. In exploring ways to reduce costs and increase efficiency, our Firstsource team had been evaluating potential uses for AI within our client’s claims operations. The client’s executive management team and board set an aggressive savings goal, which was to reduce operating costs by more than 20%. That became the catalyst for implementing the AI solutions we had proposed for claims operations. Our client did not want to wait the typical 18 to 24 months to see a return on the organization’s AI investments, however. The company needed quick wins and near-term savings.

The solution

Firstsource shares risk, delivers creative Claims as a Service solution

With our deep knowledge of our client’s claims operations and our extensive experience in deploying AI tools, we were confident Firstsource could meet the client’s cost savings goals and aggressive time frame. To ensure we could deliver, we asked the client to delegate its entire claims operation process to us. This ensured we would have full control over optimizing all upstream and downstream functions and could successfully deliver what we call Claims as a Service. In our solution, we have assumed end-to-end accountability for our client’s claims operations performance. Firstsource also shares responsibility for any state or federal penalties resulting from inaccuracies or missed deadlines. In addition, we worked through a commercial structure to deliver up front savings to the client, spreading $25M across four years.

Eliminate, accelerate and debottleneck

AI tools are essential to our “eliminate, accelerate and debottleneck” (EAD) digital accelerator framework for generating the efficiencies our client requires.

  • First, our prebuilt AI claims decision agents have eliminated a variety of manual processes for an estimated 25-30% cost savings. These modular agents have more autonomy than rules-based robotic process automation tools and continuously learn from each transaction. Our agents also are extensible and flexible so that we can easily expand and connect agents to drive automation deeper into the claims cycle and potentially the revenue cycle.
  • We also introduced AI co-pilots that help people work smarter. For example, our co-pilots Sara and SONAR anticipate and deliver the information claims examiners need to review a complex claim. Instead of spending time retrieving benefits data and operating procedure instructions, claims examiners immediately have the data they need to more quickly and accurately process complicated claims.
  • Firstsource also helped optimize operations across our client’s government health plans in different states. With our deep experience in our client’s operations, we could easily identify where in-house inefficiencies were occurring and how to reduce waste and overhead through standardizing processes.
  • Our process mining solutions will continue to pinpoint inefficiencies and bottlenecks and reveal precisely how to address them. We also executed a seamless rebadging of client personnel to deliver immediate savings and expedite implementation while ensuring knowledge retention and process continuity.

The results

Multimillion dollar savings now and over four years

AI-driven operations improvements are delivering strong results, including:

  • The AI decision agent addressed 80% of the claims for authorization edit and delivered 99%+ accuracy.
  • Our Claims co-pilot Improved productivity by more than 15% by providing claims and edit specific inputs to processors.

Our collaboration with our client’s IT, information security, enterprise architecture and core platform teams enabled quicker implementation and workflow transitions by facilitating infrastructure provisioning, security clearances and alignment with our technology stack. Each team understood how the AI agents and co-pilots would affect their operations and so we were able to anticipate and address any issues. This extensive up front work enabled us to launch a state pilot on select claim edits immediately after finalizing the client agreement.

In addition, our client’s senior management and IT leadership are strong proponents of AI. They championed the solutions and helped business professionals in the organization understand how the tools would enhance productivity and position the company for growth.

Even as we implemented the solution, AI continued to advance. The flexible AI agents and co-pilots we have deployed for our client can build on growing AI capabilities to deliver still more efficiency and provide foundational elements for extending AI-based automation throughout the organization.