Engagement overview

The processing of medical aid claims is at the heart of what the client does, with millions of Rands worth of claims processed daily.  The volumes and complexities involved are substantial and require considerable effort in maintenance and testing.  A key consideration for BSG was how to implement a legacy system change while not affecting existing daily claims processing; with a stakeholder at the client comparing the process to replacing the heart of a running man while not stopping the running man and still making sure he wins the race.

To fulfil their vision of being a world-class health operator by 2020, the client requires innovative and highly effective technology platforms.  By replacing the legacy system, the client could react quicker to customer requirements and demands, market changes and allow for increased flexibility to ensure a decrease in exposure to risk.

BSG recommended following an Agile approach, supported by customer and user experience design (CXD/UXD), to deliver off a changing requirements base early and often.  This would allow for an intuitive and user-centric system to be implemented at an enterprise-wide level, across the detailed and broad domain.  As the first significant software development project using Agile methods within the client environment, it was an extremely positive indication of the level of trust the client placed in BSG to deliver.

Once BSG had collaboratively worked with the client to scope and size the project, including defining the supporting business case for investment, business stakeholders and end-users were engaged to construct journey maps and user personas to guide detailed analysis and design work.

BSG initially reviewed how best to align the new system’s UI and user experience (UX) to user expectations and requirements.  This is part of an ongoing process to ensure an intuitive and low effort user experience.  In developing iteratively and visually (key Agile principles), the team developed a series of wireframes and prototypes to conceptualise how complex functions and concepts would practically perform, to build buy-in and real commitment from all stakeholders in the future look and feel of the system.

The wider medical claims ecosystem is vast and complex and comprises information for members, schemes, procedure details, doctors, hospitals and medications.  Therefore, when a decision about authorisation or claims processing is made, the system needs to reference information from a variety of data sources quickly and effectively, as all stakeholders want immediate, real-time decisions and feedback. This means the rules governing the system must be robust enough to handle all permutations and exceptions.  Besides sourcing and processing authorisation data, the system must interface with the claims submission networks such as hospital and pharmacy interfaces, as well as the domain-specific look-up data that informs the system’s decision-making.  Taking known and envisaged complexities into account throughout the development process has been an ongoing process for BSG, to ensure stakeholder expectations can be met.

The baseline architecture was the starting point for all future enhancements, with BSG part of a broader team working on this.  The component framework, into which the system’s core functionality could be built, was developed first and an element of this framework required determining how each of the system’s numerous components and databases would communicate with each other.

Through an Agile approach the BSG project team was able to focus on smaller and more manageable sections of the system, deliver incrementally and iteratively on small sections, meet expectations and requirements and show continuous understanding of this broad domain.

Another first for the client was the introduction of continuous integration servers, build processes and test driven development—as a continuous integration and parallel processing environment was integral to deploy the new system.

Making a difference

Making a difference in communities

Ultimately the test for any medical aid insurer is payment of claims.  Customers want to know what to expect and feel they can trust their medical aid to deliver on claim payments and authorisations.  This project enabled BSG to drive real change by partnering with the client to understand the complexities of their work and deliver a solution to not only facilitate business benefit-driven change, but drive customer loyalty.

Chief Executive Officer

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