Daily Tribune
ANG panukalang pondo ng PhilHealth ay nagmumula sa Sin Tax Reform Act, na naglalaan ng kita mula sa buwis sa alak at tabako upang suportahan at palakasin ang sistemang pangkalusugan ng bansa.
Larawan ng GMA News.
The Philippine Health Insurance Corporation (PhilHealth) is set to implement an artificial intelligence (AI)–enabled pre-validation system aimed at detecting and preventing fraudulent health insurance claims, as part of efforts to protect the integrity of its funds.
PhilHealth President and Chief Executive Officer Edwin Mercado announced the plan during a Palace briefing on Wednesday, saying the system is expected to be operational within the quarter.
Under the new setup, electronically submitted claims will be analyzed by an AI-powered platform that checks whether laboratory tests and procedures billed by hospitals are consistent with a patient’s medical diagnosis.
“So, within this quarter, we will be implementing an AI-enabled pre-validation of claims. Once e-claims are submitted, the system can already detect whether the diagnosis matches the laboratory tests conducted,” Mercado said.
He added that the technology would allow PhilHealth to flag potentially ineligible or suspicious claims at an early stage.
“Basically, at that point, we can already flag what may be potentially not qualified,” Mercado said.
In addition to technology-driven safeguards, PhilHealth is also strengthening its information and communication campaign to ensure members are fully aware of their entitlements under the national health insurance program.
“But more importantly, we want to preemptively inform our patients about the services and benefits that they should be receiving,” Mercado said.
As part of the initiative, PhilHealth will require accredited hospitals to display information materials detailing members’ rights and benefits, particularly those related to zero-balance billing and basic accommodation.
“We are strengthening our communication program and will inform patients of the benefits they are entitled to,” Mercado said.
PhilHealth officials said the combined use of advanced technology and improved public awareness is expected to reduce abuse of the system while ensuring that members receive the full benefits due to them under the law.
