The situation, in brief
PhilHealth is looking at deploying artificial intelligence to pre-screen and flag claims as the state health insurer faces a projected surge to 22 million claims in 2026, translating to more than 1.5 million claims per month. In an interview on DZRH News program Special on Saturday on June 13…
PhilHealth is looking at deploying artificial intelligence to pre-screen and flag claims as the state health insurer faces a projected surge to 22 million claims in 2026, translating to more than 1.5 million claims per month.
In an interview on DZRH News program Special on Saturday on June 13, PhilHealth President and CEO Dr. Edwin Mercado said the sheer volume of incoming claims makes technology intervention necessary to maintain the speed of processing the agency has achieved over the past year.
“Mangangailangan talaga kami ng tulong ng teknolohiya. Kaya tinitingnan namin na baka magamit ang AI at least to initially flag ang mga claims para mas mabilis naming ma-adjudicate. Otherwise, lolobo ulit iyong 22 million claims,” Mercado said.
PhilHealth has already cut its average claims processing time from 34.4 days in 2023 to 11 to 15 days at present, driven by digitalization and weekly monitoring of turnaround targets, Mercado said, with a new claims adjudication software currently being rolled out to sustain and improve on those gains.
The projected 22 million claims in 2026 is nearly double the 13 million recorded in 2023, a surge Mercado attributed to expanded access points and growing public awareness that all Filipinos are covered under the Universal Health Care law regardless of premium contributions.
He said PhilHealth is also developing pre-authorization and pre-payment review mechanisms—standard practices in private HMOs—to ensure that claims are clinically appropriate before services are rendered and before payment is released.
Mercado said benefit payments are projected to reach ₱378 billion in 2026, up from ₱119 billion in 2023, making robust claims management and fraud prevention critical to the sustainability of the fund.
He said the agency is targeting trusted providers with strong quality control, audit systems, and mortality and morbidity conferences to ensure that the expansion of elective procedures does not open the door to abuse or supplier-induced demand.
PhilHealth’s rejection and denial rate for hospital claims has also been reduced, Mercado said, partly by training hospital billing clerks on how to file claims properly—a measure that has improved the 97% payment rate on its service agreements with providers.
Former Senator and former Defense Secretary Orly Mercado, who joined the interview as a studio guest, noted that technology offers the Philippines an opportunity to leapfrog common gaps in healthcare access, saying the tools are already available and what remains is the will to harness them effectively.
