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Medscheme Transforms Claims Management Efficiency using FICO Decision Technology

Vlad Poptamas

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  • 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.”

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

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Joint Forum of Financial Market Regulators continues work on collaboration and information sharing at its Annual Meeting

Vlad Poptamas

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Photo source: slideshare.net
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The Joint Forum of Financial Market Regulators (Joint Forum) has concluded its Annual Meeting. The Joint Forum brings together members of the Canadian Council of Insurance Regulators (CCIR), the Canadian Securities Administrators (CSA), the Canadian Association of Pension Supervisory Authorities (CAPSA) and representation from the Canadian Insurance Services Regulatory Organizations (CISRO).  Representatives of the Financial Services Regulatory Authority of Ontario (FSRA) and the Mortgage Broker Regulators’ Council of Canada(MBRCC) also attended the meeting.

The dynamic nature of the financial services landscape was reflected in the Plenary Session, during which CAPSA introduced its Strategic Plan for 2019-22 and the CSA and CCIR provided highlights on its key initiatives. Themes included enhancing consumer protection and a focus on market conduct and efficiencies.

Angela Mazerolle, CAPSA Chair and Superintendent of Pensions and Insurance with the Financial and Consumer Services Commission (New Brunswick), shared CAPSA’s proposed initiatives which take into account the changing environment that has created opportunities for new plan designs, products, processes and requirements. CAPSA has considered the resulting complexities to develop a Strategic Plan that can assist pension plan administrators in meeting their fiduciary duty while protecting the entitlements of pension plan beneficiaries. The new Plan also includes a review and update of the Capital Accumulation Plans Guideline. CAPSA will collaborate with CCIR and CSA as it leads this initiative.

Louis Morisset, CSA Chair and President and CEO of the Autorité des marchés financiers presented an update on CSA members’ participation in the International Monetary Fund (IMF) Financial Sector Assessment Program (FSAP). The goals of this assessment are to gauge the stability and soundness of the financial sector and to assess its potential contribution to growth and development. The IMF assessment of the securities sector covered the analysis and review of securities and derivatives market intermediaries in Canada. Additionally, Mr. Morisset provided updates on the status of ongoing enhanced investor protection regulatory initiatives.

On behalf of CCIR, Patrick Déry, CCIR Chair and Superintendent, Solvency of the Autorité des marchés financiers brought forward two major milestones since last year’s Joint Forum meeting. In support of its priority of building cooperative supervision and aligning with best international practices, the Fair Treatment of Customers Guidance (Guidance) was released in September 2018, in partnership with CISRO. The Guidance sets out the overarching expectations of insurer and intermediary regulators across the country. CCIR also released its full fee disclosure requirements for segregated funds and is currently working with industry towards implementation. These initiatives will provide more information for consumers to make better decisions while strengthening confidence in the financial services sector. He also presented an update on the IMF FSAP assessment of the insurance sector.

This year’s meeting provided opportunities for focused discussion through break-out sessions on topical issues such as the integration of environmental, social and governance factors in investment decisions, international focus on consumer protection, financial exploitation of vulnerable investors and cybersecurity. Members were able to provide valuable insights on these issues in the cross-sectoral context. While discussing the complexities their sectors face in these areas, they were able to learn about each others’ experiences and challenges. Members also shared updates on ombudservice oversight across banking services and investments, life, health and general insurance sectors.

FSRA CEO, Mark White, provided an update on the implementation of Ontario’s new financial services regulator, including highlights of FSRA’s transformation mandate. Mr. White highlighted that FSRA’s objectives include national collaboration and harmonization of regulation, and FSRA welcomed the opportunity to engage with members of the Joint Forum.

MBRCC Chair and Director of Consumer Affairs with the Financial and Consumer Services Commission (New Brunswick), Alaina Nicholson, introduced the MBRCC and indicated that the MBRCC welcomed the opportunity to participate. Ms. Nicholson noted the broader, and often common challenges faced by financial services regulators, including the management of conflicts of interest, appropriate disclosures to consumers, product suitability, the emergence of digital service models, fintech and, of course, the increasing complexity of products.

 

SOURCE Joint Forum of Financial Market Regulators

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Regulators sign an agreement with the Financial Conduct Authority

Vlad Poptamas

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Photo source: wsj.com
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The securities regulatory authorities in AlbertaBritish ColumbiaManitobaNew BrunswickNova Scotia, Québec and Saskatchewan (participating jurisdictions) today announced a co-operation agreement with the United Kingdom Financial Conduct Authority (FCA).

The agreement extends the work of the CSA Regulatory Sandbox Initiative and the FCA Innovate project. These innovation functions provide a controlled environment for businesses to develop and test innovative solutions that promote efficiency and consumer choices in the financial sector.

“This co-operation agreement with the FCA is in addition to agreements we have reached with other regulatory organizations,” said Louis Morisset, CSA Chair and President and CEO of Québec’s Autorité des marchés financiers. “Since FinTech businesses are not constrained by national borders, it is in our best interest to share views and exchange information in connection with their activities so we can evaluate market trends and adapt our regulatory framework appropriately.”

 

CSA members have also signed agreements with the Abu Dhabi Global Market Financial Services Regulatory Authority, the Australian Securities and Investments Commission and the French Autorité des marchés financiers. Co-operation agreements are subject to the domestic laws and regulations of each authority and do not modify or supersede any applicable laws or regulatory requirements in force in, or applicable to, any such authority’s respective jurisdiction.

The CSA, the council of the securities regulators of Canada’s provinces and territories, co-ordinates and harmonizes regulation for the Canadian capital markets.

The Financial Conduct Authority is the conduct regulator for 56,000 financial services firms and financial markets in the UK and the prudential regulator for over 18,000 of those firms.

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Ally Financial Partners with Better.com to Create End-to-End Digital Mortgage Experience

Vlad Poptamas

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Ally Financial Inc. (Ally) today announced a partnership with Better.com – one of the fastest-growing digital mortgage disruptors in the U.S. – to create a new end-to-end digital experience for consumers looking for a mortgage loan from Ally. In addition to the partnership, strategic-investment arm Ally Ventures has announced an add-on investment to Better.com’s recent Series C funding, significantly increasing Ally’s overall ownership in the company. In this two-fold relationship, the online-only bank will combine capabilities with Better.com to further Ally’s position as a leading digital financial services company.

Combining the capabilities of Ally Bank with the digital platform of Better.com will bring speed and simplicity to the mortgage origination and funding process, creating a truly digital experience.

“Providing frictionless, digital experiences to our customers is core to Ally’s strategy. We’re revolutionizing digital banking by putting all of our customers’ core financial services needs at their fingertips,” said Diane Morais, Ally’s President of Consumer and Commercial Banking Products. “With Better.com, we will deliver best-in-class mortgage experiences in a highly innovative and scalable way, furthering our role as a financial ally for our customers.”

The new partnership speaks to Better.com’s cutting-edge innovation and the overall transformation of the financial services industry. Similar to Better.com’s existing platform, customers will be able to obtain pre-approval in as little as three minutes and lock in a rate in as few as 10 minutes, creating a more efficient and solution-oriented mortgage process.

“Our partnership with Ally supports our goal of transforming the mortgage industry across the board and delivering a better mortgage experience to all consumers,” said Vishal Garg, CEO and Founder of Better.com. “Additionally, with Ally’s investment in Better.com, we become partners not only in our shared vision for a seamless customer experience in home finance, but also in the long-term success and future of the mortgage industry.”

The new capabilities will be piloted in nine states including ArizonaConnecticutLouisianaNorth CarolinaOregonPennsylvaniaTennesseeTexas and Washington later this year, becoming available across the U.S. by the end of 2019.

“Strategic partnerships are an important component of our growth strategy. At Ally Ventures, we look for companies that are disrupting their industries for us to invest in and partner with to bring innovative products to the market. We felt a strong strategic and cultural fit with Better.com,” said Ally Chief Strategy Officer Dinesh Chopra. “The mortgage industry is ripe for digitalization, and our investment and partnership will allow us to deliver an industry-leading digital mortgage experience.

 

SOURCE Ally Financial

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