Victoria Bucci, Author at HealthAxis

Third party administrators (TPAs) support multiple health plans, each with distinct communication styles and member expectations. To retain clients and strengthen contract value, TPAs must deliver service that feels specific to each plan while keeping operations consistent and efficient.

A strong branded service model balances customization with structure. The goal is to let each client express its identity without creating variability that leads to errors, higher training needs, or rising service costs.

Why Branded Service Matters

Health plans expect their service partners to operate as an extension of their own teams. This requires:

Communication that reflects each plan’s terminology and tone

Predictable performance across call, email, and portal channels

Transparent workflows and reporting that reinforce trust

These expectations are tied to broader industry priorities around member experience, administrative reliability, and employer group retention.

The Core Challenge for TPAs

Serving many clients at once introduces natural complexity. Each plan may have unique benefit designs, communication protocols, escalation paths, and service level requirements. Without a grounded model, these differences can strain training, create inconsistent interactions, or increase the risk of errors. TPAs that succeed in this environment typically rely on a unified service framework that supports variation in branding and messaging without introducing operational variability.

Key Elements of a Scalable Service Model

Centralized knowledge tools to guide client specific scripts and workflows.
Shared quality standards that apply across all programs.
Dual track training that covers core skills and client branding.
Routing and segmentation that align calls with the right specialists.
Clear reporting that gives clients visibility into performance.

These elements allow customization while preserving consistency.

How BPaaS Models Strengthen TPA Service Delivery

Many TPAs use Business Process as a Service (BPaaS) partnerships to add flexibility and scale without expanding internal staff. Capabilities offered through platforms such as AxisConnect support this approach.

Branded. Service teams can communicate in a style that reflects each client’s identity.

Consistent. Standardized workflows and quality controls help maintain dependable service.

Lean. Outsourced resources reduce staffing pressure during peak periods or new client launches.

These models help TPAs expand capacity without sacrificing quality or accountability.

The Strategic Advantage

A well-designed branded service model helps TPAs:

Improve client satisfaction and retention

Speed onboarding for new contracts

Reduce training complexity

Minimize communication errors

Strengthen operational resilience

The outcome is a service operation that scales cleanly while preserving the personalized experience clients expect.

Looking Ahead

Whether through internal optimization or through BPaaS partnerships that extend capacity, the goal is the same. Every caller, member, or provider should feel as though they are speaking directly with the health plan, not an intermediary. When TPAs achieve this, they build stronger relationships, improve performance, and gain a sustainable path to scale. Learn more about how choosing the right BPaaS partner can ensure your organization delivers branded services by speaking with one of our core admin BPaaS experts.

How Commercial Health Plans Can Evaluate Fit, Plan Transitions, and Control Risk

Commercial health plans face growing pressure to contain administrative costs while meeting rising expectations for speed, accuracy, and service quality. High-volume, low-complexity work such as intake processing, data entry, enrollment updates, clean claim handling, and routine document validation consumes significant operational capacity. Many plans continue to absorb this work with internal teams that are already stretched, which often results in longer cycle times and elevated error rates.

Business Process as a Service (BPaaS) models have become a practical way to streamline these functions. BPaaS combines workflow technology, standardized operating procedures, and specialized processing teams to lift routine work off internal staff. Industry research from Gartner and Deloitte identifies BPaaS as a core driver of administrative modernization because it provides scalability, predictable cost models, and measurable performance outcomes when implemented with proper oversight.

Selecting the right partner is essential. The following criteria, transition strategies, and risk controls can help commercial plans evaluate BPaaS options with confidence.

Core Evaluation Criteria

Alignment with High-Volume, Low-Complexity Work

Not all outsourcing models are optimized for repetitive processing tasks. Plans should confirm that the BPaaS provider has proven methods for handling transactional workloads at scale, including enrollment updates, eligibility checks, primary source data entry, and clean claim validation. Providers should demonstrate consistent throughput levels and documented performance benchmarks.

Technology Enablement and Workflow Integration

A strong BPaaS model relies on configurable workflows, automation tools, and quality controls. Plans should look for integration capabilities that support existing systems, rather than requiring major platform replacements. Key areas of assessment include:

Intake automation and document digitization

Workflow routing and queue management

Audit trails and exception handling

Reporting features that support internal oversight

Quality Management and Accuracy Controls

High-volume operations require reliable accuracy. BPaaS providers should share their quality methodologies, including sampling protocols, error documentation practices, continuous improvement cycles, and compliance alignment with state and federal requirements. The provider’s approach should support NCQA, CMS, and other regulatory expectations related to data integrity.

Cost Transparency

Commercial plans increasingly seek partners that can demonstrate measurable cost reductions, not only through lower labor costs but also through streamlined cycle times and reduced rework. Pricing structures should be transparent and linked to clear output measures.

Cultural and Operational Fit

Success depends on more than technology and metrics. Plans should evaluate communication practices, staffing models, time zone coverage, training standards, and escalation paths. The provider must be able to operate as a seamless extension of internal teams.

Transition Planning That Preserves Continuity

Well-structured transitions are essential for avoiding operational disruption. A BPaaS partner should provide a clear roadmap that includes:

Process Discovery and Documentation

Before work moves to an external team, both organizations must align on current workflows, dependencies, and variations. Strong BPaaS providers use structured discovery sessions and documentation templates to map the process landscape.

Knowledge Transfer

A transition plan should include defined knowledge transfer steps, observation periods, and shadowing sessions that allow the BPaaS team to fully understand scenarios and exceptions. This phase also establishes shared definitions for accuracy and service levels.

Pilot Phases

A controlled pilot is one of the strongest safeguards for commercial plans. The pilot should cover a representative sample of work, include baseline and target metrics, and follow clear acceptance criteria. Plans can then scale to full workloads once stability is demonstrated.

Communication Structure

Regular cadence meetings, consolidated reporting, and clear escalation paths help maintain alignment throughout the transition. Plans should ensure that the provider offers structured communication protocols that match internal expectations.

Risk Controls That Strengthen Oversight

The right BPaaS partner will help plans implement oversight without adding administrative burden. Key controls include:

Service Level Agreements

SLAs should cover throughput, accuracy, turnaround time, and response requirements. They must be measurable and regularly reviewed.

Data Security and Compliance

Commercial health plans must confirm that the provider meets HIPAA, SOC 2, and other required standards. This includes secure data transmission, role based access controls, and documented incident response procedures.

Performance Dashboards

Operational dashboards allow internal leaders to monitor trends, exceptions, and SLA compliance. Plans benefit from dashboards that provide both real-time updates and historical views to support audits and process improvement.

Redundancy and Continuity Planning

Any provider supporting high-volume work should have business continuity strategies, disaster recovery plans, and redundant staffing pools to avoid service interruptions.

Where AxisConnect Fits in the Landscape

While plans should evaluate multiple partners, BPaaS models like AxisConnect illustrate how specialized operational support can reduce internal workload and improve transactional efficiency. AxisConnect teams focus on high-volume, low-complexity work and are designed to provide:

Efficient processes that increase throughput

Accurate execution supported by quality controls

Cost-effective models that reduce internal processing costs

These capabilities reflect what commercial plans should expect from any strong BPaaS offering.

Moving Forward with Confidence

The shift to BPaaS is part of a broader modernization trend across commercial health insurance. By selecting a partner that aligns with operational goals, supports transparent oversight, and provides a structured transition path, plans can achieve measurable gains in capacity, accuracy, and cost efficiency.

When you are ready to learn more about how the right BPaaS partner can elevate your operations, reach out to one of our experts.

Recent research shows that legacy systems are absorbing an average of 41% more of your IT budget just to keep running, versus having a modern solution.¹ From the vantage point of government program leaders, these legacy systems often feel like that line item you can live with for “one more budget cycle.” Because these systems technically still function, outages may appear survivable, and manual workarounds may feel manageable. Modernization, by contrast, can seem like a costly and politically complicated undertaking. Yet what rarely shows clearly in the budget is the price you are already paying to maintain those aging platforms.

For Medicaid agencies, MCOs, and other government program payers, the cost of inaction is not abstract. It shows up in administrative spend, audit exposure, staffing inefficiencies, and the ability to serve members and providers effectively.

In this article, we focus on that financial drag and how to start quantifying it in your own organization.

Legacy systems are not “free” just because they are paid off

Many public entities rationalize keeping legacy systems because the hardware is depreciated, and the software licenses are already in place. Yet independent analyses of federal IT consistently show that legacy systems consume the majority of IT spend, particularly in the public sector.

For example, federal analyses have found that agencies can spend the bulk of their IT budgets simply operating and maintaining existing systems, crowding out modernization and innovation.²

For a government health program line of business, that overhead shows up in several ways:

High “keep the lights on” operating costs for infrastructure, database licenses, and niche support vendors

Reliance on a shrinking pool of specialists who understand decades-old languages and architectures

Parallel systems and workarounds stood up to compensate for capabilities the core platform cannot deliver

On paper, the legacy platform may look inexpensive. In practice, you are paying a premium to maintain technical debt rather than to improve member and provider outcomes.

The hidden financial drains of inefficient systems

Direct IT spending is only one part of the cost of inaction. Legacy core systems create a cascade of financial impacts across your organization. Recent analyses of healthcare and public sector IT identify several consistent categories of “hidden” cost.³

Administrative bloat and rework

Government program payers already operate under tight administrative caps and scrutiny. When core systems cannot support modern workflows, the usual response is to add people, not capabilities. That leads to:

Manual eligibility and enrollment interventions to correct errors from rigid or poorly integrated systems

Duplicate data entry across claims, member, provider, and care management platforms

Manual work queues for exceptions that a modern rules engine could handle in straight-through processing

Studies of aging health IT infrastructure highlight how manual processes and fragmented systems drive labor costs and slow down revenue cycle activities.⁴ For a Medicaid MCO, that same dynamic erodes medical management effectiveness and increases administrative cost per member.

Error rates that turn into real dollars

Legacy platforms often lack modern validation, integration, and analytics capabilities. That can translate into:

Higher claim error and resubmission rates

Delayed encounter submissions to states and CMS

Difficulty reconciling premium payments, capitation, and risk-adjusted payments

Research on modernization within Medicare and Medicaid programs points out that updated systems, including cloud platforms and advanced data tools, can significantly improve claims processing accuracy and operational efficiency.⁵

Every preventable error that leads to rework, delayed payment, or audit findings has a cost. Those dollars may not be tracked under “IT,” but they belong to the legacy system ledger.

Compliance, audit, and cybersecurity risk

Older platforms often struggle to keep up with evolving security and privacy expectations. Analyses of non-compliant healthcare IT environments have highlighted how outdated systems increase the risk of penalties, breach of remediation costs, and reputational damage.⁶

For government programs, the stakes are especially high:

A single audit finding related to data quality or timeliness can trigger corrective action plans and ongoing oversight

Security incidents involving Medicaid or Marketplace data can lead to federal investigations, fines, and costly remediation

Paper-heavy or fragmented workflows make it harder to demonstrate compliance with documentation and reporting requirements

These costs are often episodic, which makes them easy to underestimate. But over the five- to ten-year horizon, they can far exceed the present net cost of targeted modernization.

Lost opportunities to leverage federal funding

CMS explicitly recognizes the need for modern Medicaid IT and offers enhanced federal matching rates for certain design, development, and implementation activities, as well as operations and maintenance of approved systems.⁷

Organizations that postpone modernization indefinitely risk missing windows where federal policy encourages and supports investment. Choosing inaction means:

Relying on state or plan funds while other entities leverage enhanced match

Limiting your ability to implement new models of care, integration with behavioral health, or improved care coordination that depend on modern data flows

In other words, inaction has an opportunity cost in available funding, not just in operating expense.

What this looks like in a government program business

For leaders in Medicaid, CHIP, Medicare Advantage, or Marketplace lines of business, the cost of inaction becomes visible in recurring scenarios such as:

Eligibility and redetermination peaks
When legacy systems cannot flex for policy changes or volume spikes, staff spend nights and weekends managing backlogs and manual workarounds. Overtime and temporary staff costs rise, and the risk of inappropriate terminations or delayed coverage increases.

New program or waiver launches
Instead of configuring products in a modern benefit and provider management platform, teams spin upside systems, spreadsheets, and bespoke interfaces. These “temporary” solutions often persist for years, each with their own support cost and risk.

Provider network changes
When provider data is scattered across multiple systems, even basic tasks like enforcing contract terms, tiering, or exclusions become heavy lifts. The result is payment errors, disputes, and inconsistent member experiences.

Reporting and analytics for oversight bodies
Legacy architectures make timely, accurate reporting to states and CMS difficult and costly. Data teams spend more time reconciling and validating than analyzing, which slows down strategic decision making.

Each of these scenarios has a cost in dollars, staff capacity, and executive focus. Taken together, they represent a structural drag on your ability to operate efficiently and to respond to policy and market changes.

Building the financial case: how to quantify the cost of inaction

For Directors and C-suite leaders, the key is to make the cost of inaction as tangible as the capital request for modernization. A practical starting point is to build a baseline in four categories.

Run and maintain spend

a. Total annual spend on infrastructure, licenses, and vendor support directly tied to legacy platforms.

b. Portion of IT budget dedicated to operations and maintenance versus new capabilities

Labor and rework

a. FTEs and contractor hours devoted to manual tasks that could be automated with modern workflows

b. Overtime and temporary labor tied to system limitations during peak events (redeterminations, new program launches)

Risk and compliance impacts

a. Historical costs of audit findings, penalties, or mandated remediation efforts linked to system shortcomings

b. Estimated cost of a plausible security incident or major outage, based on industry benchmarks

Opportunity and funding costs

a. Programs or initiatives deferred or downsized due to system constraints

b. Federal matching or grant opportunities your organization did not pursue because the underlying systems could not support the requirements

Framing modernization to reallocate these existing costs, rather than as a net new expense, often resonates more strongly with finance leaders, boards, and oversight agencies.

Where HealthAxis and AxisCore fit in

HealthAxis works with government program payers that recognize the financial drag of legacy technology but need a practical path forward. AxisCore, our modern core administration platform, is designed to:

Centralize member, provider, and claims data so teams can retire redundant systems instead of layering new tools on top of old ones

Support configurable workflows that reduce manual intervention in eligibility, enrollment, and claims

Improve visibility into operations and compliance through integrated reporting and data management

In the context of this discussion, the specific choice of platform is less important than the mindset shift: moving from funding technical debt to investing in capabilities that reduce total cost of ownership over time. For example, a legacy system typically requires 10-20 full-time developers for support and patching, while a modern custom solution would only require 2-5.⁸ AxisCore is one way to do reduce the cost over time, and we have shaped it around the needs of government program lines of business, but the core financial logic applies across all solutions.

A strategic question for leadership: what is your risk of standing still?

The real question for executive teams is not “Can we afford to modernize” but “How long can we afford to keep paying for the status quo?”

If your organization is:

Spending an increasing share of IT budget on maintenance rather than innovation

Growing headcount faster than membership, simply to keep up with administrative demands

Struggling to respond quickly to policy or program changes

Carrying growing audit, compliance, or security concerns related to legacy platforms

Then the cost of inaction is already on your income statement and in your operational risk profile.

The first step is not a full replacement project. It is a clear-eyed assessment of where your systems are creating financial drag and where targeted modernization could unlock savings and resilience.

HealthAxis can help you frame that assessment, translate operational pain points into financial terms, and explore whether a modern platform such as AxisCore aligns with your roadmap.

If you are ready to understand what inefficient legacy systems are truly costing your government program business, connect with our CAPS experts today.

Sources:

Milonda Mitchell, Compliance Officer with HealthAxis, was recently featured in an article published by Health Payer Specialist. Read Milonda’s comments below and click the link to read the full article.

How Will the New CMS Restrictions on Medicaid Taxes Impact Payers?

A recently published analysis by KFF concluded that the changes would cut expenditures on Medicaid coverage by $226 billion over the next decade, representing roughly a quarter of the deep cuts to the program that will result from the budget reconciliation package passed by Congress earlier this year. KFF estimates those cuts on taxes will lead to about 1.2 million Medicaid beneficiaries losing their coverage by 2034.

“Health plans are going to have to be creative and find more affordable ways to provide beneficiaries coverage,” said Milonda Mitchell, an executive with HealthAxis Group, a health insurance consulting firm in Tampa, Fla. “They’re going to have to be inventive and look for other subsidy grants or other funds to subsidize the cost of the cuts that are being made.”

Read the full article by Ron Shinkman here.

Claims operations in government programs rarely fail overnight. They erode slowly.

A new program is added here, a temporary policy fix is layered there, a few manual workarounds are introduced to keep up with new state or federal guidance. Before long, leaders find themselves managing a claims environment that is technically functioning, but only through constant intervention, manual effort, and staff heroics.

From our vantage point at HealthAxis, working with health plans and government program organizations, we see a common pattern. Executives sense that something is off in claims, yet the organization keeps choosing incremental patches rather than confronting the need for a strategic overhaul.

Below are five key indicators that the latter may be true.

Your claims backlog has become a permanent feature, not a temporary spike

Every plan experiences volume spikes. Seasonal enrollment changes, new benefit designs, or a large provider group shifting business can all cause short-term pressure. In a healthy claims operation, backlogs emerge and then recede as the system absorbs and adapts.

In a distressed operation, the backlog never really clears. It simply moves from red critical to amber concerning and back again.

Signs this may be true in your organization:

Aging inventory that repeatedly exceeds your internal thresholds for timely processing.

Chronic use of overtime, temporary staff, or borrowed resources from other departments to “rescue” the queue.

Leadership meetings where the same backlog metrics are discussed month after month with no lasting improvement.

Why this matters at an executive level:

Persistent backlogs increase the risk of late payments, interest penalties, and compliance findings.

Delays in adjudication diminish member and provider trust, especially in Medicaid and other government programs where populations are particularly sensitive to service reliability.

Leadership attention becomes trapped in operational firefighting instead of strategic improvement.

If your backlog has become a normal state rather than an exception, it is usually a sign that your core claims processes, underlying technology, or both are misaligned with your current scale and complexity. At that point, more staff and more patches provide only temporary relief.

You are spending more on administration without gaining flexibility or insight

Claims operations will never be cost free. The question is whether your administrative spend is buying you agility, transparency, and control, or simply propping up outdated processes.

Indicators to watch:

Year over year growth in claims related operating expenses, while productivity metrics remain flat.

High reliance on manual rework, spreadsheet tracking, and “shadow systems” maintained by specific individuals or teams.

Difficulty producing timely, reliable reports for state partners, regulators, or internal leadership without special projects and manual effort.

For government program plans, the stakes here are particularly high. Your organization must demonstrate stewardship of public funds while also adapting to frequent regulatory changes. If your administrative budget is going up, yet you still lack:

Confidence in the accuracy of performance metrics,

The ability to model the impact of benefit or policy changes on claims,

A clear view into cost drivers by program, population, or provider,

then your claims environment is not serving you as a strategic asset.

Rising administrative costs combined with stagnant or opaque performance is one of the clearest signs that incremental improvements have reached their limit.

Compliance issues feel “managed” rather than mitigated

Government program payers operate under intense oversight. Audit readiness is not optional, and regulators are increasingly sophisticated in the way they review claims, encounter submissions, and reporting.

Most organizations can survive a single adverse audit finding. The real danger arises when compliance issues become a recurring theme and the organization responds only by adding controls on top of a flawed foundation.

Warning signs include:

Repeat findings or observations in audits from state agencies, CMS, or external review entities that trace back to claims configuration, coding, or documentation gaps.

Reliance on manual checks or exception processes to prevent known errors from reaching downstream systems or regulators.

Difficulty tracing how a claim was adjudicated, which configuration rules were applied, and what data sources drove key decisions.

When compliance is managed primarily through manual oversight, “after the fact” reviews, or heroic intervention by a few highly knowledgeable staff members, your risk profile is far higher than it appears on paper.

A modern claims operation should:

Encode policy and regulatory requirements into rules that are transparent, testable, and maintainable.

Provide clear audit trails that show how a claim moved through the process and why a decision was made.

Enable rapid, controlled updates when rules change, without disruptive downtime or mass rework.

If your organization cannot comfortably meet those expectations today, it is a strong indicator that a structural uplift is needed, not just another layer of manual review.

Data lives in pockets, and no one quite trusts the “single source of truth”

For leadership, one of the most frustrating signs of distress is inconsistent data. Different teams produce different numbers, and every discussion about performance begins with a debate over whose report is correct.

In claims, this often looks like:

Separate systems for claims, provider data, member eligibility, and analytics that are loosely integrated, if at all.

Frequent data reconciliation projects to align internal records with state files or trading partners.

Key decisions about program design, network strategy, or risk arrangements being made with partial or delayed information.

This fragmentation is not just a technology problem. It directly affects your ability to manage government programs responsibly.

Disconnected data can lead to:

Incorrect payments or denials due to outdated provider or member information.

Delays and errors in encounter submissions can affect capitation payments, risk scores, and compliance standing.

Limited visibility into program performance by population segment, region, or provider group, which impairs strategy and innovation.

If your teams are spending more time reconciling, exporting, and reformatting data than analyzing it, your claims operation is signaling that it has outgrown its current architecture.

Member and provider friction keeps tracing back to claims

Member and provider experience is often treated as a separate domain from claims. In reality, claims adjudication, correctness, and timeliness heavily influence how both groups perceive your organization.

Signals to look for:

Persistent provider grievances related to underpayments, denials, or unclear remittance advice.

Escalations from advocacy teams, case managers, or call centers that ultimately trace back to claims processing decisions, benefit interpretation, or data mismatches.

High contact rates from members seeking clarity on what was paid, what they owe, and why.

For government programs in particular, trust is fragile. Members and community providers are quick to notice when payments are slow, explanations are confusing, or patterns of error seem to disadvantage certain services or populations.

If your teams are working hard to improve the experience but find that many of the root causes lie within claims, it is a strong indicator that a deeper rethink is required. Improving scripting and training in the call center, for example, can only go so far if the underlying adjudication logic is complex, inconsistent, or opaque.

When patches stop working: reframing the decision

Recognizing these indicators is only the first step. The harder step is choosing to treat them as a mandate for transformation rather than simply more evidence that “claims is complicated.”

Directors and C-level leaders often hesitate to pursue a full claims overhaul for understandable reasons:

Perceived risk of disruption to ongoing operations and regulatory obligations.

Concerns about cost and budget cycles.

The institutional memory of prior large projects that fell short of expectations.

At HealthAxis, we see organizations move forward successfully when they reframe the decision around three questions:

What is the cost of staying where we are, over the next 3 to 5 years?
Consider not only direct operating costs, but also audit risk, opportunity cost, and the impact on member and provider experience.

What would we be able to do that we cannot do today, if claims were modernized?
For example, support new payment models, integrate more closely with state systems, or respond faster to policy changes.

What level of change is necessary to achieve those outcomes?
Small fixes may bring marginal gains, but structural challenges in rules configuration, data integration, or workflow orchestration typically require more than incremental tuning.

Practical next steps for leaders

If several of these indicators resonate with your current environment, you do not need to jump immediately into a full technology selection process. Instead, we encourage leaders in government program organizations to begin with a structured assessment.

Here are concrete steps you can take:

Map your current claims ecosystem at an executive level
Document the major systems, vendors, and manual processes involved in moving a claim from receipt to final disposition, including reporting and encounter submission. The goal is not technical detail, but clarity about where fragmentation and handoffs exist.

Align on a small set of non-negotiable outcomes
For example: “reduce average claim turnaround time by X,” “eliminate repeat audit findings in area Y,” or “achieve a unified view of claims, member, and provider data for government programs.” These targets will anchor future decisions.

Identify where manual workarounds hide structural issues
Ask leaders and front-line staff which steps in the process rely on spreadsheets, personal expertise, or ad hoc communication to keep things moving. Those areas are often where an overhaul will deliver the greatest value.

Engage stakeholders beyond operations and IT
Bring compliance, finance, provider relations, and government affairs into the discussion. Claims touches all of them, and their perspectives will help define the business case and risk picture more completely.

Explore options with a clear view of your organizational strategy
Modernizing claims does not always mean replacing everything at once. It may involve replatforming, adopting business process as a service in specific areas, or reconfiguring and integrating existing assets. The right path will depend on your scale, regulatory context, and internal capabilities.

How HealthAxis fits into the conversation

HealthAxis exists to help payers and government program organizations move from fragile, patchwork claims operations to environments that are reliable, compliant, and adaptable.

We believe the most important decision is not which solution you eventually choose, but when you recognize that continual patching is no longer serving your mission or your members.

If the indicators in this article feel familiar:

Persistent backlogs,

Rising administrative cost without clarity,

Compliance issues that keep resurfacing,

Fragmented data,

And mounting friction for members and providers,

then your claims process is sending a clear message.

When you are ready to explore what a more stable and future-ready model could look like, chat with our Medicaid experts!

Insurance providers in the government sector face growing pressure to manage higher enrollment volumes, more complex documentation requirements, and continuous policy changes. Many of the tasks associated with this operational load are repetitive. These include data entry, document processing, file validation, and portions of eligibility verification. They are essential functions, but they place significant strain on internal teams whose time would be better spent on member engagement, compliance oversight, and program integrity.

A structured sourcing model for back-office functions can help organizations meet these demands without adding headcount or straining existing systems. By aligning repetitive work with external support teams that specialize in operational processing, plans can improve accuracy and throughput while maintaining a predictable cost structure.

Below is a practical approach that public program organizations can use to evaluate and implement a modern business process as a service (BPaaS) or business process outsourcing (BPO) partner for back-office work.

Why Back-Office Sourcing Matters for Public Programs

Medicaid and Marketplace plans must consistently handle high volumes of administrative work. Agencies and managed care organizations face several ongoing challenges:

Volume volatility throughout the year
Redetermination cycles, open enrollment, and policy-driven eligibility checks can sharply increase task volume. Internal teams are rarely staffed to efficiently absorb these fluctuations.
High administrative burden tied to documentation
Government programs require extensive document handling for identity, residency, household information, income validation, and program compliance. Manual processing increases the risk of bottlenecks.
Persistent error risks in repetitive tasks
Manual data entry and document indexing are prone to errors when completed at scale. In a public program environment, these errors can delay coverage determinations and frustrate members.
Pressure to improve service delivery without increasing cost
State contracts and regulatory expectations emphasize efficiency and accuracy. Many organizations must meet these expectations without significant increases in administrative staffing.

A sourcing model that shifts repeatable work to specialized processing teams helps meet these demands while supporting consistency and turnaround time.

Building an Effective Sourcing Model

A sourcing strategy for public program back-office work focuses on aligning tasks with the right level of expertise and workflow support.

Identify the tasks that benefit most from external handling

Suitable functions typically include work that is:

High volume
• Repetitive
• Rules-based
• Dependent on accuracy
• Time sensitive

Examples include document classification, data entry into core systems, eligibility checklist validation, and form quality checks.

These workflows lend themselves to structured processing support that follows documented standard operating procedures aligned with federal and state requirements.

Implement controls that maintain visibility and compliance

Even when work is sourced externally, public program organizations must retain oversight of compliance. This often includes:

Clear SLAs for timeliness and accuracy
• Auditable workflows
• Defined escalation paths
• Consistent reporting dashboards
• Role-based access to systems and documents

These elements allow plans to maintain control and accountability while still benefiting from external support capacity.

Integrate sourced workflows into existing operations

A sourcing model should not function as a standalone process. Smooth integration minimizes friction and reduces the need for internal rework. Helpful approaches include:

Standardized file formats
• Shared workflow tools
• Routine calibration sessions
• Feedback loops between internal and external teams

This creates continuity across tasks and supports reliable throughput.

How Sourcing Improves Plan Performance

When implemented carefully, a sourcing approach can support several organizational goals:

Improved throughput
High-volume tasks move more consistently, reducing backlogs and supporting timely eligibility decisions.

Reduced administrative strain
Core staff spend less time on manual work and more time on complex cases, provider interactions, or quality initiatives.

Better member experience
Faster document handling and fewer processing errors translate to fewer delays and clearer communication.

More predictable operational costs
Sourcing can stabilize expenses by using structured pricing and defined capacity.

These benefits align directly with the needs of public program payers working to maintain service quality, as requirements continue to evolve and cost is closely guarded.

Moving Toward a Scalable Sourcing Strategy

As public program workloads continue to shift with policy changes, enrollment dynamics, and compliance expectations, health plans need operational models that can flex without losing speed or accuracy. A thoughtful sourcing model helps organizations keep administrative work on track while preserving their internal teams’ focus.

If your organization is evaluating how to streamline back-office operations or strengthen your processing capacity, HealthAxis can provide perspective on models, workflows, and structures that support government program requirements. We are available to discuss approaches that help reduce internal administrative load while improving the reliability of day-to-day processing. Learn more about AxisConnect, our comprehensive suite of business service offerings, or talk to a team member about what the next best step is for your operation.

In this last blog in our series on the impact of the One Big Beautiful Bill Act for payers, risk-bearing providers, and third-party administrators (TPAs), we explored how Medicaid and Marketplace eligibility changes, including updates to income verification and stricter documentation requirements, are likely to increase churn and intensify IT needs. Yet the operational impact runs far deeper. Regulatory updates, shifting payment rules, expanded community engagement expectations, and more complex verification responsibilities all introduce new workloads that require consistent, scalable execution.

Across the industry, organizations are turning to automated, flexible, and scalable solutions to manage these demands. These service models offer flexible staffing, standardized workflows, and quality oversight that adapt to regulatory shifts without placing all new responsibilities on internal teams.

Why flexible operational capacity is mission-critical

As states and plans work through the many provisions of H.R.1, they must maintain day-to-day operations that directly affect program accuracy and member experience. This includes verification tasks, documentation reviews, redetermination support, provider data updates, and timely response to regulatory reporting needs. New HCBS waiver processes, community engagement attestation, and financial policy changes will require additional effort from enrollment units, customer service teams, fiscal operations, and compliance departments. Section 1115 demonstrations must align with evolving federal guidance, which places new emphasis on monitoring, data accuracy, and continuous oversight.

These shifts create fluctuating workloads throughout the year, making flexible operational capacity an essential strategic tool rather than a temporary fix.

Where BPaaS and BPO models add value

Waiver and eligibility operations: BPaaS and BPO teams can support tasks connected to HCBS eligibility reviews, needs-based assessments, documentation tracking, and required reporting. By translating program rules into consistent workflows, organizations can manage higher volumes without compromising accuracy.

Monitoring and reporting readiness: With oversight requirements becoming more detailed, service models can sustain reporting cycles, data validation routines, and audit preparation. This is especially relevant where agencies must follow frameworks such as those described in SMD 24-003.

Financial and enrollment operations: As payment caps and provider tax limits influence rate structures and planning, operational teams often face increased reconciliation, enrollment validation, and billing review activity. Outsourced or shared service teams help carry this workload during peak periods.

Integration and execution of new processes: Duplicate enrollee checks, community engagement tracking, and Marketplace verification all require routine execution. BPaaS and BPO teams can manage these tasks with established procedures, freeing internal staff for higher-level decision-making.

Supporting long-term operational resilience

BPaaS and BPO models are designed to scale. When redetermination volumes spike or new rules introduce sudden workload increases, service teams can expand capacity quickly. As processes stabilize, capacity can adjust without disrupting internal operations. This provides organizations with predictable support, consistent quality, and the ability to meet regulatory expectations even when internal staffing is constrained.

Government program payers face a period of considerable change. The operational demands introduced by H.R.1 will require precision, adaptability, and reliable execution. BPaaS and BPO solutions offer a path to maintain compliance and protect member experience while managing workloads that rise and fall with each policy cycle.

Suraya Yahaya,

President and CEO of HealthAxis

Introduction

Payers and providers today face a complex mix of challenges: mounting administrative costs, inconsistent data insights, increasing regulatory pressure, and the ongoing shift toward value-based care. These challenges are magnified by fragmented systems and disjointed strategies that make scalability difficult.

The partnership between COPE Health Solutions and HealthAxis directly targets these pain points. By combining advanced analytics, operational expertise, and intelligent automation, the two organizations deliver a fully integrated solution that empowers health plans, provider-sponsored plans, and ACOs to move from strategy to execution with confidence.

Pain Point 1: Disconnected Data and Limited Population Health Insight

The Challenge:
Many payers and providers operate with fragmented data systems that make it challenging to understand risk, manage quality, or coordinate care effectively. Without actionable insight, it’s nearly impossible to improve outcomes or control costs.

Our Solution:
COPE Health Solutions’ Population Health Management (PHM) platform consolidates and interprets data from clinical, financial, and social sources, transforming it into actionable intelligence. Paired with HealthAxis’ analytics-enhanced back-office support, organizations can:

Identify and close care gaps across populations.

Use predictive analytics to manage risk and utilization.

Improve care coordination between payers and providers.

The Result: Greater visibility into member health trends, better outcomes, and improved performance on quality measures.

Pain Point 2: Transitioning to Value-Based Care

The Challenge:
Moving from fee-for-service to value-based care requires operational readiness, aligned incentives, and accurate data sharing between payers and providers. Many organizations struggle with the infrastructure and analytics needed to support these models.

Our Solution:
Together, COPE Health Solutions and HealthAxis deliver an integrated framework that supports value-based care from every angle.

COPE Health Solutions helps organizations design and implement value-based models, define success metrics, and align incentives.

HealthAxis operationalizes these strategies through automation, integrated data workflows, and compliance monitoring.

The Result: A faster, more confident transition to value-based care that supports clinical excellence, financial sustainability, and member satisfaction.

Pain Point 3: Rising Medical Loss Ratio (MLR) and Cost Pressures

The Challenge:
High MLR and rising administrative costs continue to erode margins. Traditional cost-cutting measures often sacrifice quality or scalability, leading to short-term savings but long-term instability.

Our Solution:
Through a coordinated approach, the partnership helps clients address both cost and quality simultaneously.

COPE Health Solutions provides data-driven financial modeling to forecast MLR and identify opportunities for cost containment without compromising care quality.

HealthAxis introduces automation and workflow optimization that reduce manual labor, eliminate redundancies, and enhance accuracy in claims processing.

The Result: Sustainable cost reduction, improved compliance, and stronger financial performance across all business lines.

Pain Point 4: Administrative Complexity and Operational Inefficiency

The Challenge:
Health plans are struggling to contain administrative costs while maintaining accuracy and compliance. Manual processes, siloed systems, and legacy infrastructure slow down operations and reduce the member and provider experience.

Our Solution:
HealthAxis’ AxisConnect BPaaS platform integrates claims administration, provider management, and member services into a single, intelligent workflow. Combined with COPE Health Solutions’ operational consulting and performance frameworks, organizations gain:

Streamlined workflows that reduce administrative overhead.

AI-enabled automation that minimizes errors and accelerates processing.

Scalable infrastructure that supports growth across multiple lines of business.

The Result: Lower operational costs, faster turnaround times, and a measurable improvement in administrative accuracy.

Conclusion: A Partnership Built for the Future of Healthcare

The collaboration between COPE Health Solutions and HealthAxis is more than an integration of tools and services; it’s a strategic alignment built to solve healthcare’s most persistent pain points.

By uniting data-driven insight, operational excellence, and intelligent automation, this partnership empowers payers and providers to streamline operations, control costs, and deliver higher-quality care at scale.

This is the path to a smarter, leaner, and more connected health ecosystem, one where strategy and execution finally operate as one. Schedule a call today to learn more about this partnership and how it can benefit your organization.

How Modern Platforms Like AxisCore Transform Member and Provider Experiences

A seamless onboarding process is one of the clearest indicators of operational excellence. Yet for many payers, onboarding new members and providers remains fragmented across multiple systems, leading to duplicate data entry, manual errors, and delays that erode satisfaction and retention.

HealthAxis understands that first impressions matter. Onboarding is more than an administrative process; it is the foundation for trust, accuracy, and long-term engagement. That is why our core administration platform, AxisCore, is designed to unify onboarding workflows for both members and providers, turning what was once a complex and error-prone process into a streamlined, data-driven experience.

Breaking Down Silos Through Centralized Data

Legacy systems often store member and provider data in separate databases, making coordination and verification time-consuming. AxisCore replaces those silos with a centralized data architecture, enabling a single, accurate source of truth across the organization.

With real-time access to enrollment, credentialing, and eligibility data, commercial payers can reduce redundancy and ensure consistency across departments, from customer service to compliance. This not only accelerates onboarding but also improves data accuracy for downstream operations.

Efficiency Through Integrated Workflows

Manual onboarding workflows are slow and resource intensive. AxisCore introduces automated, rules-based workflows that guide staff through each step of the process while maintaining full visibility. Tasks like eligibility verification, provider credentialing, and document routing can be completed faster and with fewer handoffs.

The result is improved efficiency and scalability, payers can handle higher volumes without compromising quality or compliance. Members and providers experience quicker approvals and fewer delays, which translates into higher satisfaction and stronger retention.

Customization, Automation, and Compliance

Every commercial payer has unique business rules, partner relationships, and regulatory requirements. AxisCore’s flexible framework allows organizations to customize workflows and automate compliance checks, adapting seamlessly to plan-specific needs. The platform continuously aligns data and processes with evolving federal and state requirements, reducing the administrative burden of compliance management.

By automating checks for credentialing accuracy, member eligibility, and enrollment documentation, payers not only stay compliant but also gain the agility to adjust quickly when regulations or market demands shift.

A Seamless Onboarding Experience That Builds Loyalty

Delivering a seamless onboarding experience is no longer optional; it is essential to maintaining a competitive advantage. With AxisCore, payers can move from disconnected systems to a unified, intelligent onboarding process that strengthens relationships with both members and providers.

By centralizing data, streamlining workflows, and ensuring built-in compliance, AxisCore helps commercial payers turn onboarding into an opportunity to differentiate on experience, efficiency, and trust. Watch a demo of AxisCore to learn more today.

In our previous blog, we focused on the new implementation demands of the One Big Beautiful Bill Act (OBBBA) facing states and MCOs. These demands and operational shifts directly affect how members move between Medicaid and Marketplace coverage. To further explore this ripple effect, read below on how eligibility and verification changes are likely to drive membership shifts, coverage churn, and heightened IT requirements for payers.

Specifically, coverage churn is not just a technical problem; it’s a member experience problem. HealthAxis has the capabilities to equip payers with the tools and services needed to make coverage transitions seamless and compliant.

Why churn will rise

Tighter Medicaid eligibility processes (semiannual redeterminations, community engagement verification) and enhanced Marketplace verification for premium tax credits (PTCs) will increase “boundary movement” between coverage programs. H.R. 1 directs exchanges to verify income, family size, lawful presence, residence, and coverage status and expands recapture of excess advance PTCs, with changes taking effect as early as 2028. Plans serving both Medicaid and Marketplace populations should expect more frequent transitions, terminations, appeals, and reconciliation events.

Individuals who disagree with Marketplace eligibility decisions continue to retain formal appeal rights (generally 90 days from the notice date), underscoring the need for well-orchestrated member communications and documentation. Plans that help members navigate appeals and special enrollment periods (SEPs) can reduce abrasion and speed of time to coverage.

Roadmap to Alignment

AxisConnect BPO for Marketplace Operations:

Appeals & Grievances Support: Intake, evidence-gathering, and submission support aligned with federal timelines.

Member Communications Using Marketplace Systems: Proactive campaigns to explain PTC verification, documentation checklists, and SEP triggers when Medicaid ends.

Enrollment Support Using Marketplace Systems: Hands-on assistance with plan selection, binder payments, and 834 issue resolution to minimize gaps.

AxisCore Automation & Reconciliation:

Eligibility Reconciliation: Automated nightly jobs to match Marketplace decisions with plan systems and resolve discrepancies.

Grace Period Customization: Custom build rules around grace periods to ensure accurate communication and processing for members resolving outstanding premium bills.

Cross-Program Transitions: Event-driven workflows that create seamless disenroll/re-enroll sequences when members move between Medicaid and Marketplace.

Strategic benefit

Plans that harden the seams between programs, technologically and operationally, will keep members covered and costs predictable despite higher churn. AxisCore and AxisConnect together provide the rails and the operational muscle to make that happen.

HealthAxis partners with plans to build resilience so that, even in times of change, members experience continuity, compliance remains strong, and operations remain sustainable. Our scalable, modular approach delivers enterprise-grade technology and service without complexity or fixed cost. With a single partner for both technology and operations, plans are implemented faster, support is more responsive, and solutions are designed around their unique size and growth ambitions.

Author:

Suraya Yahaya,

President and CEO of HealthAxis

See Our Solutions in Action

Why Branded Service Matters

The Core Challenge for TPAs

Key Elements of a Scalable Service Model

How BPaaS Models Strengthen TPA Service Delivery

The Strategic Advantage

Looking Ahead

How Commercial Health Plans Can Evaluate Fit, Plan Transitions, and Control Risk

Core Evaluation Criteria

Where AxisConnect Fits in the Landscape

Moving Forward with Confidence

Legacy systems are not “free” just because they are paid off

The hidden financial drains of inefficient systems

What this looks like in a government program business

Building the financial case: how to quantify the cost of inaction

Where HealthAxis and AxisCore fit in

A strategic question for leadership: what is your risk of standing still?

When patches stop working: reframing the decision

Practical next steps for leaders

How HealthAxis fits into the conversation

Why Back-Office Sourcing Matters for Public Programs

Building an Effective Sourcing Model

How Sourcing Improves Plan Performance

Moving Toward a Scalable Sourcing Strategy

Introduction

Pain Point 1: Disconnected Data and Limited Population Health Insight

Pain Point 2: Transitioning to Value-Based Care

Pain Point 3: Rising Medical Loss Ratio (MLR) and Cost Pressures

Pain Point 4: Administrative Complexity and Operational Inefficiency

Conclusion: A Partnership Built for the Future of Healthcare

How Modern Platforms Like AxisCore Transform Member and Provider Experiences

Breaking Down Silos Through Centralized Data

Efficiency Through Integrated Workflows

Customization, Automation, and Compliance

A Seamless Onboarding Experience That Builds Loyalty

Why churn will rise

Roadmap to Alignment

Strategic benefit

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Our Solutions