The client is a leading healthcare provider, operating a number of major healthcare facilities within South Africa. When a patient is treated and makes use of these facilities, a claims management process is initiated between the healthcare provider and the various fund administrators to recover the costs involved. 

The client processes medical claims with the major fund administrators through a B2B straight-through process intended to minimise manual intervention and reduce errors. A large percentage of claims processed by the fund administrator are however still rejected or short-paid, typically as a result of the ever-changing environment. Rejected claims are then manually investigated by the client’s internal team. The manual resolution process can be up to three times longer than a claim processed without issue. In some cases, these claims are written-off as a bad debt. 

BSG proposed a collaborative approach, using a team with both generalist and specialist skillsets to help the client better use their data. This enabled the client to reduce the number of claim rejections and improve the ability to recover claim payments from the fund administrators. 

BSG succeeded in delivering actionable results in 8 weeks with a team of 4 people. The predictive model was able to predict high-risk cases, with more than 80% accuracy, resulting in estimated benefit realisation of approximately R40 million a month.