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.
President and CEO of HealthAxis
