Medscheme Transforms Claims Management Efficiency using FICO Decision Technology

• Medscheme has created a modern decision platform for its Medical Aid Administration business, which reviews some 400,000 claim lines per day, based on FICO^® Blaze Advisor decision rules management system
• Medscheme won the 2018 FICO^® Decisions Award for Decision Management Innovation
• Medscheme is one of South Africa’s largest providers of administrative and health risk management solutions for the healthcare sector

Medscheme, one of South Africa’s largest providers of administrative and health risk management solutions for the healthcare sector, has created a modern decision platform for its Medical Aid Administration business, which reviews some 400,000 claim lines per day. The innovative solution, powered by FICO^® Blaze Advisor decision rules management system, reduced claim interventions by 15 percent in a six-month period, and has dramatically reduced the time needed to change business rules and strategies.

For its achievements, Medscheme won a 2018 FICO^® Decisions Award for Decision Management Innovation.

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“Our vision is to create a world with sustainable healthcare, and at the heart of our business is processing medical claims of members and healthcare providers,” said Denise Sleem, general manager and project lead at Medscheme. “By modernizing our claims management capabilities, we have become more agile, more efficient and more effective, which means members and healthcare providers get faster answers on claims.”

“Our focus is on efficient and effective administration services that are optimized and responsive to varying medical scheme needs at any given time,” said Andrew Wright, executive manager for Shared and Support Services at Medscheme. “We thus need to constantly challenge the way we work and where we wish to invest in enhancing our broader healthcare administration capabilities that will ensure they are relevant into the future.

“Furthermore, Medscheme requires flexibility in its claims capability, which is especially important today as we bring on board new clients with thousands of members with their own set of rules. Our claims engine needs to easily accommodate the variety of client scheme needs and integrate seamlessly with our core administration system, with very little room for errors or delays.”

Transforming a Legacy System
In rebuilding their claims management system, Medscheme had clear requirements. They needed modern, scalable technology that could support their needs into the future, integrate well with the rest of their IT infrastructure, and meet stringent SLAs for claim review times. The new system had to make rules and policies visible, be accessible to business and technical teams, and be much easier and quicker to change.

“The business rules that informed our decisions in our claims processing were mostly locked up in code, data and people’s minds,” explained Sleem. “We had to discover them, document them and move them swiftly into the new system. FICO has been a terrific partner for us in this effort.”

Medscheme created a framework using cloud-native technologies including Kubernetes, Docker and Spring Boot, within which the FICO Blaze Advisor decision rules system runs. “This environment is extremely scalable, and can be used either on-premise or with any of the big three cloud provider spaces, and can be run in a hybrid model as well,” said Drikus Britz, lead solutions architect at Medscheme. “The solution allows for zero downtime deployments within a day should the need arise. We are running in an active-active mode across multiple data centers, allowing for almost zero downtime during disaster recovery situations for real-time claims.”

Due to the high volume and complex rules associated with medical claims, Medscheme needed to think carefully about performance. “We use Hazelcast to cache information related to our clinical data that does not have a high frequency of change,” Britz said. “This allowed for the decision engine itself to remain stateless, while having frequently used information a lot ‘closer’ to the engines, which drastically improved speed. To further improve performance, we enhanced the components that serialize and de-serialize the incoming and outgoing requests to and from Blaze Advisor. We also have moved to a semi de-normalized object model inside Blaze Advisor, which gives us the most efficient way of rule writing and execution at runtime.”

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Clear Benefits to Modernization
Medscheme has recorded a number of benefits of their new system:

• Fast processing of an average of 400,000 claim lines per day
• Easy to respond to a query about a decision, due to fully documented business rules
• Claim interventions reduced by 15 percent over a six-month period
• 99.9% uptime — a stable product on a stable platform with the ability to do online deployments
• Ability to respond quickly to market changes and varied client requirements
• Multiple resources able to work on multiple changes to the decision services code at a time
• A consolidated rules management repository enables flexibility and traceability of decisions
• More agile rule capabilities for changing benefit designs, allowing for increased volume and complexity

“We are impressed by the technical ingenuity of the Medscheme team,” said Nikhil Behl, vice president of marketing at FICO. “This is a fantastic solution to a common problem — modernizing a legacy system to improve efficiency and customer satisfaction.”

FICO^® Blaze Advisor decision rules management system gives businesses maximum control over high-volume operational decisions. Blaze Advisor provides companies with a scalable solution that delivers unprecedented agility and actionability for smarter business decisions. FICO Blaze Advisor is part of the groundbreaking FICO^® Decision Management Suite for building and deploying decision management applications.

Photo source: SOURCE FICO