South Africa Healthcare Claims Management Market Analysis

South Africa Healthcare Claims Management Market Executive Summary

The South Africa healthcare claims management market is projected to grow from $173.55 Mn in 2022 to $1010.2 Mn by 2030, registering a CAGR of 24.63% during the forecast period of 2022 – 2030. In South Africa, national health spending as a percentage of GDP in 2019 was 9.11% or $547 per person.

The South African healthcare claim management market is expanding significantly as a result of the rising demand for healthcare services and the necessity for effective healthcare claim management solutions. Many parties are involved in the South African healthcare claim management sector, including healthcare providers, insurance providers, governments, and third-party administrators (TPAs). Third-party administrators (TPAs) are specialised businesses that manage claims on behalf of healthcare providers or insurance firms.

Market Dynamics

Market Growth Drivers

The South African healthcare claims management market is expected to be driven by factors such as:

1. Increasing demand for quality healthcare- People in South Africa are expecting higher-quality healthcare services as they become more aware of their rights and entitlements in this area. As a result, there is an increasing requirement for healthcare claims management solutions that can boost the effectiveness and quality of healthcare delivery
2. Rising healthcare costs- The expense of healthcare is rising in South Africa as a result of the ageing population, the prevalence of chronic diseases, and technological advancements in medicine. As a result, there is an increasing need for healthcare claims management solutions that are efficient and effective in order to assist cut expenses
3. The growing use of technology- Electronic health records, telemedicine, and mobile health solutions are some of the digital technologies that are increasingly being used in South Africa's healthcare system. The demand for increasingly sophisticated and integrated healthcare claims management solutions that can operate in unison with these technologies is being driven by this
4. Government support- The South African government has started a number of projects to enhance the provision of healthcare services in the nation and is aggressively encouraging the use of technology in healthcare. The market for healthcare claims management has grown favourably as a result of this

Market Restraints

The following factors are expected to limit the growth of the healthcare claims management market in South Africa:

1. Limited access to healthcare- Although South Africa's healthcare coverage is expanding, some regions, especially those in rural and underdeveloped areas, still have limited access to healthcare services. This might lower the need in these regions for healthcare claims management solutions
2. Regulatory challenges- the South African healthcare sector is subject to stringent rules and compliance standards, which can make it difficult for businesses to enter and operate in the market. This might reduce the number of competitors in the market for healthcare claims management
3. Limited technical expertise- Using cutting-edge healthcare claims management strategies necessitates specific technical knowledge, that could be scarce in some regions of South Africa. This might make it more difficult for insurers and healthcare providers to accept and apply these solutions

Competitive Landscape

Key Players

• Medscheme (ZAF)- one of South Africa's major administrative and health risk management solution providers for the healthcare industry, Medscheme, has developed a cutting-edge decision platform for its Medical Aid Administration division, which examines over 400,000 claim lines each day. Processing medical claims from members and healthcare providers are at the core of the business, and their vision is to create a world with sustainable healthcare
• Discovery Health (ZAF)- offers administration and managed care services to more than 3.3 million beneficiaries, and is the top medical scheme administrator in South Africa. The company handles 18 limited medical schemes on behalf of prestigious corporate clients and Discovery Health Medical Plan, South Africa's largest open medical scheme, and has a market share of over 40% of the country's medical scheme market. The pharmacy claims management system, called Discovery ProPBM, was developed to provide a wide array of managed care services to the medical schemes it oversees
• Medikredit (ZAF)- In South Africa, claims management and healthcare innovation have been led by MediKredit. Their experience in pharmaceutical benefit administration, claims to switch and processing for physicians and hospitals in the public and private sectors, provider network management, and real-time connectivity to healthcare funders is part of their global, electronic health benefits management (HeBM®) practise
• AXA- healthcare insurance is one of the many insurance products and services offered by AXA, a multinational insurance provider. They provide healthcare claim-handling services in South Africa
• Cigna- operates in South Africa and offers medical, dental, disability, life, accident, and related products and services, as well as global health services
• Allianz- is a major international provider of financial services that offers life and health insurance to both private citizens and businesses. For dental operations, outpatient care, and hospital stays, they offer claim administration

Notable News and Upcoming Events

April 2019- The creative approach, supported by the FICO Blaze AdvisorTM decision rules management system, significantly decreased the time required to modify business rules and strategies and reduced claim interventions by 15% over a six-month period. Medscheme received a 2018 FICO Decisions Award for Decision Management Innovation in recognition of its accomplishments.

July 2023- The first Insurance Claims Conference will be held by Umbono Conferences and Events on July 6, 2023, at the Focus Rooms in Mooderfontein. The purpose of this conference is to bring together the most important stakeholders in the insurance sector to debate and discuss ways to help insurers deal with difficulties such as a decline in fraudulent and dishonest claims. The operational and financial effects of the COVID-19 epidemic on the insurance sector must also be discussed.