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Erscheinungsjahr: 
2025
Schriftenreihe/Nr.: 
PIDS Discussion Paper Series No. 2025-52
Verlag: 
Philippine Institute for Development Studies (PIDS), Quezon City
Zusammenfassung: 
Fraud in social health insurance results in inefficient use of government resources and diverts funds away from paying for necessary health care needs and subsidizing the poor. We conducted a process evaluation of the fraud control mechanisms of the Philippine Health Insurance Corporation (PhilHealth) to identify gaps and challenges in fraud prevention, detection, and deterrence and to provide realistic and evidence-based policy recommendations to strengthen these mechanisms and ensure their coherence in light of the provider payment system's transition to a prospective global budget (GB) based on diagnosisrelated groups (DRGs). Through stakeholder consultations with relevant PhilHealth offices, literature reviews, and descriptive analyses of fraud data, we found that PhilHealth fraud control mechanisms do not flag all potential fraudulent activities common to DRG-GB systems. PhilHealth lacks an overarching fraud control strategy across prevention, detection, and deterrence mechanisms, leading to a focus on reactive detection measures that take effect only after health care is provided or claims have been filed. Rather than proactively monitoring providers, PhilHealth's reliance on pre-authorization to prevent fraud emphasizes costcontainment over setting incentives for efficient and quality service delivery. These challenges are exacerbated by limited human and information technology resources, leading to a lack of routine data monitoring and analysis. Consequently, PhilHealth's current fraud control activities severely underestimate the incidence of health insurance fraud in the country. Moving forward, PhilHealth's fraud control system requires development of a framework that covers different types of gaming across the continuum of care and processes to translate provider performance monitoring into payment incentives, supported by increased investments in staff and technologies. These findings and recommendations are especially relevant as the Philippines transitions to a DRG-GB payment system, which provides an opportunity to incentivize quality service delivery through pay-for-performance purchasing. Strengthening PhilHealth's fraud control mechanisms is a vital step to realizing the agency's commitment to guarantee affordable, acceptable, available and accessible health care services for the Filipino people.
Schlagwörter: 
PhilHealth
health insurance fraud
Philippines
provider payment reform
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Dokumentart: 
Working Paper

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