Case Study: Medscheme achieves scalable, agile, transparent claims management with FICO Blaze Advisor (Customer: Medscheme; Solution provider: FICO)

Medscheme Overhauls Its Claims System to Deliver Better Strategies

Medscheme, a leading South African healthcare administrator serving 2.1 million beneficiaries across 18 medical schemes, faced a legacy claims platform that was inflexible, created IT bottlenecks and hindered its ability to respond quickly to market, regulatory and client-specific changes. The company needed a scalable, transparent and agile claims solution to handle growing volumes, varied funding models and reduce manual interventions.

Medscheme implemented FICO Blaze Advisor as a three‑phase decision rules engine (adjudication, pricing, benefits) to modernize claims processing. The new system processes about 400,000 claim lines per day (≈12 million per month), cut manual claim interventions by ~15% in six months, delivers 99.9% uptime, improves rule traceability and speed to market, and enabled an award‑winning fraud control capability; knowledge transfer also made Medscheme autonomous to maintain and extend the solution.

Medscheme

Denise Sleem

General Manager