Eye Surgeries Billed Twice, Up to 4,000 Patients Hit: The Violations Were Known, the Fines Never Came

An eye operation, paid for twice. Once by the Health Insurance Fund, and once out of the pocket of a patient who had no idea the Fund had already paid. According to the criminal complaint, that is how the scheme worked - a scheme that hit between 3,000 and 4,000 patients and left the Fund's (FZO) budget about 1.7 million euros short.

Police, working with the Prosecutor's Office for Organized Crime and Corruption, searched several locations in Skopje and one each in Tetovo and Kumanovo. Eight people were detained, and around 50,000 euros in cash plus mobile phones were seized. The complaint targets 11 individuals, including one Albanian citizen, as well as the private healthcare facility itself - for money laundering.

How the scheme worked

According to the complaint, in 2020 two then-directors of the Fund, together with a representative of the private hospital, signed a contract that went against the Fund's own procedures and internal rules. Then, using false data in the electronic system and invoices with false content, the hospital billed the same service to both sides. On top of the legal co-payment, patients were charged a private price - and nobody told them the Fund had already paid for the very same operation.

The numbers in the complaint: 104,818,754 denars of damage to the Fund through payments on fictitious invoices, another 525,000 denars in contractual penalties never collected, and an unlawful gain for the hospital of 261 million denars, about 4.25 million euros, over 2022-2025. According to media reports, the hospital is "Sante Plus", and among those named in the complaint is former Fund director Den Dončev. Everyone involved is presumed innocent until a court says otherwise.

The inspectors who didn't inspect

The most interesting part of the complaint isn't the hospital - it's the people who were supposed to stop it. The head of the Fund's Control Sector is suspected of never forwarding reports on the irregularities he found to the responsible commission, and of postponing routine inspections. Two managers at the Fund's Skopje regional office are suspected of failing to collect fines that had already been imposed, so the Fund kept paying the facility without offsetting what it owed.

Health Minister Sašo Klekovski, who says he launched the investigation while he was head of the Fund, delivered what may be the worst sentence in the whole story himself: the facility engaged in "constant repetition of similar violations for which it was not adequately punished". He called it a "chain of impunity" - and, in his own words, it went on for years.

That's the real question. If one hospital can bill the same operation twice for years, with violations logged and never punished, how many other contracts with the Fund are passing through inspections that don't inspect? And how many of those 3,000-plus patients will ever see their money again?