January 8, 2026
Manila – The Philippine Health Insurance Corporation (PhilHealth) is considering the use of an artificial intelligence (AI)-powered pre-verification system to prevent fraudulent health insurance claims and protect its funds.
Edwin Mercado, president and chief executive officer of PhilHealth, said at a palace briefing on Wednesday that the system electronically checks submitted claims to determine whether a patient's laboratory tests match the medical diagnosis.
Read: Budget watchers warn of growing PhilHealth funding shortfall
“Therefore, within this quarter, we will be implementing something like pre-validation of insurance claims powered by AI. Once an electronic claim is submitted, the system will be able to detect whether the diagnosis matches the lab tests performed,” he said in Filipino.
“So basically, at that stage, we will already be able to indicate which patients are potentially ineligible,” the PhilHealth chief added in Filipino.
Mercado's statement is in line with calls by the Philippine Institute for Development Studies (PIDS), a state-run think tank, for stricter enforcement of anti-fraud measures within the province's health insurance companies.
Read: PIDS study calls for stronger PhilHealth fraud controls
“PhilHealth should expand its definition of fraud, strengthen anti-fraud mechanisms, and develop a strategic plan to deter providers from abusing the system,” PIDS said in its latest discussion paper.
“To do this, PhilHealth should expand its scope of current fraud to include not only those that may emerge as the system moves to global budgeting, but also other potential fraud that occurs across the continuum of care,” it added. /jpv
