The challenge: Aging core ecosystem unable to support member-centric vision
Our client provides healthcare coverage to more than half the residents in its state through a mix of health plans, including commercial, Medicare Advantage and managed Medicaid. The health payer wanted to evolve from interacting with its members as a financial intermediary and claims processor to a true health organization that helps members achieve their health and wellness goals. That’s a critical shift for health payers to make as the industry moves away from fee-for-service payment and emphasizes value-based care.
To free resources to create member well-being initiatives, our client needed to reduce its operating and technology costs. At the same time, it required a modern core administrative platform that could support value-based care models while optimizing processing efficiencies. Its existing platform and many critical applications were outdated. Meeting newer compliance regulations required custom integrations and processes that drove up maintenance and operating costs. Processing inefficiencies had resulted in a backlog of manual work, with some work more than a year old.
Given the scope of its needs, and its rising medical loss and administrative loss ratios, the health payer determined it did not have the internal capacity to realize its vision and released an RFP for business process as a service (BPaaS) solutions.
The solution: Comprehensive BPaaS from a Modern Cloud-Ready Core
After a rigorous review process, the health plan selected Firstsource for our deep expertise, the tight alignment of our comprehensive services, global capacity, partner ecosystem and platform-agnostic best-of-breed approach with their business goals, and our ability to ensure a smooth transition.
Now we are the lead service provider, responsible for managing technology partners under a single contract with clear, predictable per member per month pricing, and delivering business outcomes across membership, enrollment, claims administration, provider credentialing, provider data maintenance, provider calls, mailroom, print and fulfilment and operational reporting.
The results: Streamlined, modern systems support population health and member well being
As we upgraded our client’s legacy core administration platform, we rationalized and optimized technology across hundreds of business-critical applications. Using digital accelerators from the outset, including AI/ML, process mining and digital twins, we pinpointed root causes and revamped processes to improve operations efficiency.
One example: by reimagining the provider contact center, the client has improved their provider experience.  At the start of our engagement, contact center hold times averaged more than 60 minutes, resulting in high abandon rates and provider complaints. By extension, member experience was being impacted when providers could not get answers about eligibility, prior authorizations, claims status, etc. Since implementing visual IVR, call scripting and automation, calls are now answered within 90 seconds and the center’s abandonment rate is less than 2%, a best-in-class standard for the industry.
Overall, BPaaS has reduced the client’s administrative costs by approximately 30% across IT and BPO, and reduced technology debt by up to 50%. These results have enabled the client to make greater investments in member-facing health and wellness initiatives, and increased  focus on population health and community care.
