Our Business

Delivering on strategy

Every year on 1 January, Medscheme releases a fully renewed set of benefits and limits for all our schemes. It is a massive undertaking that requires absolute accuracy, flawless execution, and unwavering commitment.

While most of the organisation enjoys a well-deserved year-end break, several dedicated teams work tirelessly behind the scenes to ensure that every benefit change, rule configuration, and system update is delivered without disruption to our members.  

This annual year-end programme is not simply a routine update. It is one of Medscheme’s largest and most critical strategic projects, ensuring members can seamlessly access their benefits from day one of the new benefit cycle. 

A coordinated effort across exceptional teams 

Every year from September through January, multiple teams collaborate day and night to interpret scheme rules, configure system changes, develop new functionality, test thousands of scenarios, and resolve every defect – all to guarantee operational readiness by 1 January. 

This year, the following teams and leaders played a central role: 

Exceptional delivery under exceptional pressure 

Despite receiving signed-off annexures and scheme rules significantly later than expected, and despite several schemes introducing new rules requiring development and extensive testing, the teams demonstrated extraordinary resilience and skill. 

Together, they delivered: 

  • HBM Auth DE = 162 New / Rule changes, roughly 1 000 test scenarios loaded on QC, manually executed and results validated, 132 defects resolved
  • 37 040 test scenarios executed 
  • 317 defects resolved 
  • Approximately 300 Scheme Rule Annexures reviewed over 61 benefit options 
  • 503 YE related ResQ calls logged by the MCOS team for system configuration 
  • 336 HEM coding rules reviewed across all coding structures and scheme options 
  • 184 clinical policies reviewed 
  • 250 medicine formulary lists created 
  • 90,000 NAPPI codes coded into the Chronic Medicine Adjudication Engine 
  • 430 CCSA codes and 6 949 RVUs reviewed and mastered 
  • 944 real-time claims manually checked on 1 January 2026 
  • 2 529 medicine rules checked and updated 
  • 622 New / Rule changes NEXUS Adjudication DE – 622 New / Rule changes
  • 51 new plan benefits created – NEXUS Benefits DE
  • 1037 rate categories updated equating to over 500 000 new rates loaded by the NEXUS Maintenance team
  • 3496 limits updated by the NEXUS Maintenance team

Most impressively, the team accomplished all of this in just six weeks. This is a remarkable achievement, especially considering the reduced capacity, tight deadlines, and holiday-period constraints. Many of them sacrificed personal time with family and friends during the summer break to ensure our clients and members experienced zero disruption when the new benefit year began. 

Collaboration made success possible 

None of this would not have been successful without the invaluable support from our business units and their seconded staff members, who worked alongside the core teams to test rules, validate configurations, and ensure accuracy.

Their partnership ensured that every rule was tested rigorously and every scheme was fully prepared for activation. 

A celebration of excellence 

The successful completion of the 2026 year-end project stands as a testament to: 

  • the expertise of our technical and business teams
  • the strength of our cross-functional collaboration
  • the unwavering commitment to our clients and members

This is not just an annual operational requirement, it is one of Medscheme’s largest, most strategically significant achievements, delivered through teamwork, tenacity, and deep pride in the work we do. 

Thank you to every individual involved – your dedication ensured that Medscheme once again delivered excellence where it matters most. 

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