By Brian Campued
The Philippine Health Insurance Corporation (PhilHealth) is intensifying its fraud detection measures to ensure that only legitimate health insurance claims will be processed.
In a press briefing on Wednesday, PhilHealth President and Chief Executive Officer Edwin Mercado said that the agency will use a pre-validation system powered by artificial intelligence to analyze submitted claims to determine whether patients’ laboratory tests match their medical diagnoses.
“Mayroon na po tayong isasagawa within this quarter na parang AI-enabled na pre-validation ng mga claims. Kapag pinasok po ‘yung e-claims, made-detect na po kung nagma-match ‘yung diagnosis doon sa mga lab test na ginawa,” Mercado said.
“So, basically, doon pa lang mapa-flag na namin kung ano ‘yung potentially hindi karapat-dapat,” he added.
Mercado made the remarks when asked about the recent study made by the state-run think tank Philippine Institute for Development Studies (PIDS), calling for an overhaul of PhilHealth’s fraud control measures as the system transitions to a global setup.
“So, ngayong taong ito po, marami po kaming nilagay na mga gates, kumbaga po may mga pre-authorization, mayroong pre-validation para maiwasan. Kasi mas maganda po na preemptive iyong pagsasala natin kung ano po iyong mga iko-cover natin kaysa na-deliver na iyong care tapos lalo na kung nabayaran na namin at saka namin hahabulin,” he stressed.
For the Yaman ng Kalusugan Program (YAKAP), Mercado noted, technology-driven measures are being undertaken such as biometrics checking, validation of the “liveness” of the patient based on medical records, and the attachment of empanelment slips detailing the benefits that the patient must receive before the state health insurer releases the payment to the healthcare provider.
Information drives will also be intensified regarding the benefit packages that members may avail from the state health insurer, including the zero balance billing and Z Benefit Package programs.
“Marami pa rin ang hindi nakakaalam ng mga benepisyo ng PhilHealth. Isa na po ito sa mga pagbabagong ginagawa natin… Ngayon po talaga, naglagay po kami ng boots on ground na talaga pong maggagalugad ng mga ospital at saka mga clinic lalo na po itong YAKAP, at ito po ay in-approve ng board na may mga dagdag po tayong mga tao dito,” Mercado said.
“So, ayon po, pinapalakas namin ‘yung aming communication program… at i-inform po namin ‘yung mga pasyente kung ano po ‘yung kanilang mga benepisyong dapat natatamasa,” he added.
Under the 2026 General Appropriations Act (GAA) signed by President Ferdinand R. Marcos Jr. on Monday, PhilHealth received nearly P129.8 billion in funds intended for the continuous expansion of its benefit packages, improve preventive healthcare services, and reduce the out-of-pocket expenses of every Filipino family.
“Ang aprubadong budget po ng PhilHealth ngayong taon ay tinitingnan po natin na isang lehitimong pagkilala sa mga repormang ating inumpisahan… Kumpiyansa tayo na sapat ang pondo ngayon,” Mercado said.
-av
