PhilHealth to use AI against fraud

THE Philippine Health Insurance Corp. (PhilHealth) will implement artificial intelligence (AI) in strengthening its fraud control measures, its chief said on Wednesday, following a state think tank’s recommendation for an overhaul.

PhilHealth President and Chief Executive Officer Edwin M. Mercado said the state health insurer has already tightened “gates” this year through pre-authorization and pre-validation measures designed to stop questionable claims before payments are made.

“This year, we put in place many ‘gates,’ such as pre-authorization and pre-validation, to prevent problems,” he told a Palace briefing in Filipino.

“It is better to preemptively screen what will be covered rather than allowing care to be delivered first — especially after we have already paid and only then try to recover the funds.”

The approach marks a move away from post-payment recovery, which he said is more costly and difficult once care has been delivered and reimbursed.

Mr. Mercado was responding to a recent Philippine Institute for Development Studies report that called for an overhaul of PhilHealth’s fraud control framework, including a shift to proactive monitoring and an expanded definition of fraud under the global budget system.

He noted the study drew on data from previous years and said reforms have since accelerated.

Within the current quarter, PhilHealth will pilot AI-enabled pre-validation of electronic claims, Mr. Mercado said.

The system is designed to flag inconsistencies by checking whether diagnoses align with laboratory tests submitted, allowing the insurer to block potentially ineligible claims at the point of filing.

Beyond technology, PhilHealth is also ramping up patient-facing measures to address information gaps that can enable abuse.

Mr. Mercado said the agency will roll out hospital posters detailing members’ rights and benefits, including zero-balance billing and coverage under Z benefit packages at accredited facilities, to ensure patients know when they should not be charged. — Chloe Mari A. Hufana