PhilHealth eyes AI-powered system to detect fraud in health claims

MANILA, Philippines — The Philippine Health Insurance Corporation (PhilHealth) is eyeing the use of an artificial intelligence (AI)–powered pre-validation system to prevent fraudulent health insurance claims and safeguard its funds.

The system will electronically check submitted claims to determine whether patients’ laboratory tests match their medical diagnoses, PhilHealth President and Chief Executive Officer Edwin Mercado said during a Palace briefing on Wednesday.

READ: Budget watchers flag swelling PhilHealth fund gap

“So, within this quarter, we will be implementing something like an AI-enabled pre-validation of claims. Once the e-claims are submitted, the system will be able to detect whether the diagnosis matches the laboratory tests that were conducted,” he said in Filipino.

“So, basically, at that stage, we will already be able to flag which ones are potentially not eligible,” the PhilHealth chief added in Filipino.

Mercado’s statement aligns with a call by the state-run think tank Philippine Institute for Development Studies (PIDS) for tighter implementation of fraud control measures within the state health insurer.

READ: PIDS study calls for tighter PhilHealth fraud controls

“PhilHealth must develop a strategic plan to broaden the definition of fraud, strengthen fraud prevention mechanisms, and deter providers from gaming the system,” PIDS said in its latest discussion paper.

“To carry this out, PhilHealth should expand the current scope of fraud to include other potential fraudulent practices that occur within the continuum of care, as well as those that can emerge as the system transitions to a global budget setup,” it added. /jpv