We run claims, enrollment, appeals and member engagement for 8 of the top 10 US health plans, each model designed for the plan behind it.
Leader in Healthcare Payer Business Process Transformation
Leader in Healthcare Payer Intelligent Operations
Leader in Healthcare Payer Agility & Innovation
Leader in Payer Transformation on Healthcare Digital Services
Stars pressure, margin squeeze, and regulatory deadlines all land in the same place—the back office.
Real outcomes from live health plan programs. Not projected benchmarks.
Each solution targets where cost and risk sit on a health plan's book. Use one or run the whole operation.
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.
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.
Most denial and late-payment risks surface in the data before they hit the book. Process mining and ML models flag them early, with $40M in late-payment interest recovered at a top-5 plan.
A missed appeals deadline costs Stars points, not just a grievance. Firstsource cuts urgent turnaround from 12 hours to 4 hours, with 99.5% of appeals resolved within that window at 99.99% accuracy.
Bad provider data is a denial before it happens. Firstsource runs credentialing, demographic updates, and directory accuracy at sub-15-day turnaround and 100% audit accuracy across 230,000 files a year.
Generic outreach doesn't move hard-to-reach populations. We build psychographic-segmented, multilingual programs that drive HRA completion, care-gap closure, and scaled visit adherence.
Paper is where the back office slows. Firstsource converts claims, EOBs, and appeals at above 99.6% field accuracy, with 100% TAT adherence across a 30-minute to 48-hour processing window.
End-to-end claims, enrollment, member services, appeals, and provider operations on a single PMPM, with technology migration funded from year-one savings and outcomes in the contract.
Each plan type runs under its own regulators, margin pressures, and operating logic. Generic models fail here.
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.
Regional and Blues plans face local regulation and multi-platform administration costs. We deliver BPaaS transformations that cut admin spend 20%, eliminate half of tech debt, and deliver 9-figure savings.
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.
Dental benefit administrators run thin margins and heavy configuration. We raised tier 1 dental claims accuracy and run a dedicated dental BPaaS for a multi-million member book.
Vision benefit administration: rolling benefit tracking, real-time accumulator data sharing, and benefit-limit enforcement across member, provider, and plan systems.
Moving claims operations to global delivery raised accuracy and member satisfaction at the same time as it lowered cost.
A top-5 national health plan running Medicare, Medicaid, and Marketplace lines across 20 states engaged Firstsource to build claims as a service: agentic workflows, copilots for top claim pends, and process mining across more than 100 million claims.
Talk to our teamOutcomes, compliance, intelligence, and cost accountability. Every program is built on all four.
Every engagement runs on Kairos OS. Process mining identifies friction early. Predictive AI sets the order of work.
CMS, HIPAA, HITRUST, TCPA, and state rules sit inside the workflow. We enable compliant claims delivery across all 50 states.
We get paid when you save. No upfront capital bill: the technology migration is funded from operating savings from year one.
We run operations for 8 of the top 10 US health plans, process 75 million manual claims a year, and capture 220 million claims of data annually.
Discover Kairos, the operating system that turns health plan domain knowledge into a durable, compounding asset for claims, enrollment, and member operations, with 25+ years of health plan data baked in.
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