Key Findings & Highlights:

Health plans are increasingly prioritizing the modernization of legacy platforms and highly manual workflows as a foundation for improving claims accuracy, meeting evolving regulatory requirements, and enabling greater operational scalability. These efforts are less about wholesale system replacement and more focused on stabilizing core platforms, reducing technical debt, and creating a more resilient operating environment that can support future automation and analytics initiatives.

In parallel, BPS vendors are embedding automation and analytics across claims, member, and provider-facing functions to reduce rework, shorten turnaround times, and improve audit accuracy. This includes the use of rules-based automation, workflow tools, and analytics layers that sit on top of existing systems to improve process consistency and operational transparency without disrupting core adjudication or servicing platforms.

GenAI adoption remains largely tactical rather than transformational at this stage. Health plans and BPS vendors are applying GenAI to targeted use cases such as call summarization, claim classification, documentation support, and prior authorization triage. These deployments are delivering early efficiency gains and measurable cost savings, but are typically implemented in controlled, narrow scopes to mitigate risk and ensure regulatory compliance.

Provider data management, credentialing, and payment integrity remain dominant areas of focus for transformation. Automation is being applied to improve data accuracy, streamline credentialing workflows, and reduce overpayment exposure through more consistent identification of billing errors, duplicate claims, and contract compliance issues.

To balance compliance requirements with cost efficiency and speed of execution, hybrid delivery models combining onshore, nearshore, and offshore resources continue to expand. These models allow health plans to retain regulatory-sensitive activities onshore, while leveraging global delivery for scale, flexibility, and cost optimization during transitions and steady-state operations.

Outcome-based engagement metrics are increasingly embedded in contract performance frameworks. Measures such as adjudication rates, appeal reduction, and member experience indicators, including NPS and CSAT, are increasingly used to align vendor incentives with business outcomes rather than solely using input-based metrics such as FTEs or volume/transaction-based commercial models.

Lastly, BPS vendors are increasingly coupling IT and BPS delivery within integrated platform-led frameworks. This approach is intended to strengthen accountability, improve cross-functional visibility, and accelerate deployment cycles by reducing handoffs between technology and operations teams and enabling more coordinated transformation execution.