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PhilHealth to implement AI-enabled pre-validation system to prevent fraudulent claims

7 January 2026

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

In a Palace briefing on Wednesday, PhilHealth President and Chief Executive Officer Edwin Mercado said the AI-enabled pre-validation system will analyze electronically submitted claims to determine whether patients’ lab tests match their medical diagnoses.

“So, 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 said.

Aside from technology-driven measures, PhilHealth is also strengthening proper communication and information dissemination about the benefit packages offered to members.

“Pero ang mas importante, preemptively ‘yun nga pong mga pasyente natin na mapaliwanagan kung ano po ‘yung mga serbisyo at saka ‘yung mga benepisyong kailangang nakukuha nila,” Mercado said.

Mercado said PhilHealth will post information materials in accredited hospitals about their rights and benefits, particularly on zero-balance billing and basic accommodation.

“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,” Mercado said. | PND