Engagement
Africa
Claims Platform Modernisation
Metropolitan Health Cape Town, South AfricaApr 2015 — Aug 2016
Business analysis on modernisation of the claims adjudication platform serving multiple South African medical schemes.
Digital Health
Claims
Operations
Decisioning
Context
Metropolitan Health's claims platform was the engine for several large medical schemes but auto-adjudication rates had plateaued, driving high manual handling.
Challenge
Modernise rules and exception handling to lift straight-through processing without compromising scheme-specific benefit logic.
Role
Business Analyst — adjudication rules and exception workflows.
Actions taken
- Catalogued 1,400+ benefit rules across 6 schemes
- Co-designed a layered rule architecture (core + scheme overlays)
- Authored exception taxonomy and routing logic
- Defined SLA dashboards for ops and scheme reporting
Impact
Auto-adjudication rate lifted from 61% to 87%
- Auto-adjudication rate lifted from 61% to 87%
- Average claim turnaround down from 9 days to 2
- Provider disputes down 36%
- Ops headcount redeployed: 18 FTE moved to value-add work
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