HIFRNM: The Fund treats the SAO’s remarks in the final report with seriousness and continuously acts to implement them

In relation to the journalistic questions received concerning the Audit Report of the State Audit Office, the Health Insurance Fund informs the public that it acts fully and continuously upon the audit report on the work of the Fund. The report greatly facilitates the detection of problems and enables the Fund to focus on their elimination, thereby enabling the development of the work, as well as increasing the efficiency and quality of the health services that the Fund provides to citizens.

Below, the Fund provides the following information relating to certain remarks in the report on the work of the Fund. 

Regarding the remark concerning the non-filling of managerial posts, the Fund fills new positions every year through public and internal announcements, on the basis of the Fund’s Employment Plan. Accordingly, with regard to 2021, which is the year to which the SAO report relates, 54 employees left the Fund, two sector directors were appointed and 14 new persons were employed, of whom 9 are in managerial posts. By comparison, in 2022, in accordance with the Employment Plan for the same year, the planned vacancies through retirement and announced departures are 79 employees, and there are 79 new employments, of which 12 are managerial posts. In this way, the Fund is continuously acting in relation to the SAO’s remark on the non-filling of posts.

Regarding the remark concerning control activities in the exercise of health insurance rights, we clarify that the control activities noted by the SAO are the subject and work of investigative authorities. The Fund carries out control on the basis of legally prescribed parameters and has no investigative powers.

Regarding the systemic and manual controls in the process of prescribing and dispensing medicines, the Fund established the shortcomings. From 01.04.2021, changes to the application were installed in the Fund’s IT system, whereby, during the electronic validation of data from prescription invoices, systemic control of the unique prescription number, which is mandatory data, was introduced. Control of the unique prescription number prevents the same number from appearing multiple times for each separate invoice.
 

• Additionally, on 13.10.2021, all Regional Offices of the Fund were instructed to perform additional control of prescription items which appeared in the Fund’s IT system with the same unique prescription number more than once, and which relate to prescriptions for narcotics and acute therapy. The Regional Offices reduced the amounts established as invalid. 
• Following this activity, the Fund enabled connection with the My Appointment system and the retrieval of data obtained from it. It also introduced additional control mechanisms which began to be used for prescription invoices from April 2022. The result of this control and connection is the prevention of payment for invalid prescriptions. 
• Finally, in 2022 the Fund completed the procurement procedure for cloud rental services for a primary and secondary data centre, on which the software intended for prescribing, dispensing and invoicing prescriptions will be installed. With this step, the Fund will establish real-time control over the dispensing of medicines, as also noted in the SAO’s final report for 2021, submitted on 23 January 2023. 

 
Regarding the functioning of the Fund’s IT system, the final report on the audit performed by the auditors of the State Audit Office, submitted on 23 January 2023, that is, last month, indicates that:

During 2022, a public procurement procedure was initiated for services for renting a private cloud for a primary and secondary data centre in the Fund and for migration of applications and data, with which the situation is expected to be overcome

The public procurement was announced on 30.09.2022, while the contract was concluded on 09.12.2022, with the selected company starting work from 1 January 2023. According to the plan and specification, the first phase, namely the migration of the system infrastructure, should be implemented in February, after which phase the migration of the application and data infrastructure would begin.

Concerning the remark on the imposition of contractual penalties, the Fund informs that the finding relates to 2020 and 2021, when PHIs and PHIs functioned under pandemic conditions and when outstanding contractual penalties existed. With the establishment of the new Commissions, work was carried out continuously to clear the backlog, and this situation is being overcome. 

Regarding the remark on the approval and implementation of conditional compensation in PHIs, for the needs of PHIs the Fund approves conditional budgets strictly for dedicated procurements (for example, procurement of medicines that are not on the positive list but are necessary for treating patients). In 2022, there is a changed practice in which the funds are paid after presentation of an invoice for procurement of the specific medicine, in order to ensure maximum control, in accordance with the previous indications of the SAO. 

Regarding the remark on the payment of maternity leave compensation, the Fund independently identified this shortcoming. This concerns a period in 2020 and 2021 under pandemic conditions, upon a decision of the Government of the Republic of North Macedonia whereby maternity sick leave was extended under pandemic conditions. During the extension, a certain number of employers did not report that some mothers had returned to regular employment, and therefore some mothers received both maternity sick leave and regular monthly compensation. Upon identifying this problem, the Fund acted immediately, whereby most employers corrected the regular monthly compensations, while for those for whom this situation has not been corrected (around 60 in number), an individual approach was taken in order to overcome the problem. 

As also noted by the SAO’s final audit report submitted on 23 January 2023, and relating to the audit for 2021 “during the audit, activities were undertaken by the Fund:

• installation of automatic controls in the sick leave module
• re-control of all payments where salary was simultaneously paid by the employer and salary compensation for maternity leave
• organisation of a working meeting with representatives of the PRO for the purpose of adapting a software solution for integrated collection of contributions

Regarding the remark in the procedure for referral for treatment abroad, as also noted by the SAO’s final audit report submitted on 23 January 2023, and relating to the audit for 2021, “In August 2022, a rulebook was adopted on the manner of using health services by insured persons abroad, which, among other things, regulates the conclusion of contracts with health institutions abroad, the criteria and procedure for selecting them, and also covers the manner of using health services in PHIs in the RNM” With this rulebook, the SAO’s remark is fully overcome. 

Concerning the remark on the state of part of the liabilities in the financial statements, due to the control mechanisms introduced by the Fund for carrying out the process of controlling invoices, a time difference arises from receipt to recording, but it does not affect the final deadline for payment of the invoice. This principle is not usual, but represents additional protection when paying the Fund’s funds.

Regarding the provision of all health services for insured persons, the Fund has concluded contracts with all PHIs that have received a decision for entry into the network from the Ministry of Health and have submitted a request to the Fund for the conclusion of contracts for entry into the network. That procedure is established by the Law on Health Care and the Law on Health Insurance.