Three years running, the state auditors write the same thing. A German hospital has twelve active court cases against the Health Insurance Fund and is seeking 433,771 euros - unpaid invoices for treating Macedonian patients abroad. Three reports, the same remark, the same outcome.

In total, the Fund faces 21 lawsuits inside the country, worth around 286.6 million denars. That is a figure that never turns up in any press release about the health system's achievements.

The billions the institutions owe each other

The biggest number in the State Audit Office's review of the Fund's 2024 operations does not come from hospitals. It comes from the state itself.

By the end of 2024, the Health Ministry had failed to transfer around 2.136 billion denars to the Fund - roughly 35 million euros - for uninsured citizens. The pension fund, meanwhile, pays contributions for pensioners irregularly. Unpaid contributions in total reach 8.4 billion denars.

The auditors write that late transfers of funds affect the Fund's liquidity. Translated: an institution that owes hospitals because other institutions owe it. Ping-pong with public money, and at the end of the chain stands a patient waiting for a service.

Seventeen out of forty-two IT posts

Some of the findings are remarkably concrete. The Fund has 42 IT positions on its books. Seventeen are filled. The rest is covered by external contractors - even though the system's code is the Fund's own property.

The information security policy has not been revised since 2014. There is no business continuity plan in case of a breakdown. The module for tracking treatment abroad is underused, and the data is entered after treatment has already finished rather than in real time.

Out of 362 requests for treatment abroad, the legal deadline of 45 days was missed in 39 cases. For someone waiting on approval for surgery outside the country, those days are not statistics.

Money nobody asked to get back

The auditors also found that about half of all advance payments relate to the period from 2014 to 2023, for which final invoices were never received or the money was never returned. Uncollected receivables from foreign health institutions amount to 296 million denars. There are also 194 active bankruptcy proceedings with claims of over 619 million denars, with incomplete records of the assets acquired through them.

Each of these findings can be explained on its own. Together, they describe a system that knows how much it is owed, knows who it owes, and has no mechanism either to collect or to pay on time.

And what stings most is the least spectacular part: the auditors have written this for a third year in a row. If the report changes nothing, who is it serving?