The system checks every claim. It pays what was agreed, and nothing else.
A claim is typed in, and the system checks it against the membership rules you put in and the price list you agreed with that hospital. Anything not on the contract is turned down. Anything priced above the agreed rate is turned down. Anything outside the member's cover is turned down. Your staff only see the few claims that genuinely need a person.
Run your own past claims through it and compare the decisions. Nothing to commit to.
A claim being decided — who is covered, what was claimed, what the agreed price allows.
The current way
Paying what was never agreed is the easiest money to lose
A claim checked by eye, against a price list in a drawer, is a claim you cannot predict, price or defend afterwards.
Current way
Claims arrive by email, portal and paper and are sorted out by hand.
Consequence
Some wait days, some wait weeks, and hospitals phone your desk to ask where theirs is.
Bigger problem
Hospitals lose patience and stop giving you their better prices.
Current way
Staff check limits and prices from documents and memory.
Consequence
Items that were never on the contract get paid, and prices above the agreed rate get paid with them.
Bigger problem
You cannot price a product when nobody is sure what it actually pays out.
Current way
Exceptions are agreed in a corridor and written down loosely.
Consequence
Nobody can explain later why a claim was paid outside the rules.
Bigger problem
Losses only show up at audit, a year after you could have stopped them.
How it works with M‑Care Suite instead
The system does the checking, your people judge the rest
Every claim is run against your membership rules and the agreed price list before a person sees it. Only what passes can be paid.
Set up
You put in your rules and every agreed price list, with a wizard
The membership rules from your plans, and the price list you signed with each hospital — item by item, with the agreed rate against each one — plus who in your office may approve what. Your staff can load a price list from a spreadsheet.
Your plan rules
Price list per hospital
Who approves what
Result
The contract you signed is the contract the system applies.
The system checks
Three tests, on every single claim
Is this member covered today, and is the service inside their cover? Is the item on the price list agreed with this hospital? Is the amount charged within the agreed price? A claim has to pass all three.
Cover and limits
On the contract
At the agreed price
Result
Your staff stop looking things up in documents.
The system rejects
What fails is turned down, with the reason
An item that is not on the contract is not paid. A price above the agreed rate is not paid. A service outside the member's cover is not paid. The hospital is told which item failed and why, so it can be corrected instead of argued about.
Not on contract — rejected
Above agreed price — rejected
Outside cover — rejected
Result
Money stops going out on things you never agreed to pay for.
You only see
The few claims that need a person
Claims that pass every test are priced at the agreed rate and lined up for payment on their own. Only real exceptions come to your staff, sent to the right person by amount and by reason.
Clean claims pass
Exceptions only
To the right person
Result
A small team can handle a large book of claims.
You get
A record you can defend
Every check, answer, rejection and payment shows who did it, when, and on what basis — ready for your auditors and the regulator.
Full history
Reasons recorded
Reports for the actuary
Result
You see money leaking while you can still stop it.
Worried about letting a system check claims?
Most claims teams are. Here's how M‑Care Suite proves itself on your own past claims before it decides a single new one.
You might be thinking
“We cannot risk wrong answers at scale.”
What we do
Run your own past claims through it first.
Put a batch of claims you have already paid through the free trial and compare what the system says with what your team decided. We go through every difference with you before anything goes live.
Your own past claims, run again.
You might be thinking
“Our staff will lose control.”
What we do
You decide what the system may do alone.
You set the amounts and the reasons that must reach a person. Everything else the system finishes on its own.
Approval limits you set, per scheme.
You might be thinking
“Hospitals will not accept being turned down by a system.”
What we do
They are told exactly which item failed and why.
A rejection names the item, the agreed price and the reason, so the hospital can correct and resend instead of phoning to argue. It is your own signed price list doing the talking.
Reason given on every rejected item.
Check it against claims you have already paid
Put one of your schemes and one hospital price list in yourself, run your past claims through it, and see what the system would have paid — and what it would have turned down.
Run your own past claims through it and compare the decisions. Nothing to commit to.
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