Police officers, on the orders of the Basic State Prosecutor's Office in Podgorica, have been investigating suspicions for more than a year that the private health institution Polyclinic Hipokrat submitted falsified reports on the provision of magnetic resonance imaging services to the Health Insurance Fund (HIF), in order to qualify for payment from the HIF budget.
The police are acting on a report filed by the Health Insurance Fund on March 27, 2024, with the Criminal Police Station for Suppression of Economic Crime, while they submitted the documentation on November 22 last year.
In 2023, the Hippocrates Polyclinic and the Health Insurance Fund signed a contract on the provision of specialist, consultative and diagnostic healthcare in the field of radiological diagnostics, which is valid from January 1, 2024 until the end of 2025. This contract allows insured persons to undergo magnetic resonance imaging in a private clinic at the expense of the Health Insurance Fund.
Due to the lack of MRI machines and long waiting lists, the Health Insurance Fund has been sending patients to three private clinics with which it has signed contracts for years. In addition to the Hippocrates Polyclinic in Podgorica, contracts have also been signed with the Konzilijum and Moj Lab polyclinics.
The public healthcare system of Montenegro has four magnetic resonance imaging machines, three of which are located at the Clinical Center of Montenegro in Podgorica, one at the Clinical Hospital Center in Berane, while the new device intended for the General Hospital in Bar is still not in operation.
Contracts with private clinics stipulate that magnetic resonance imaging examinations of HIF insured persons can only be performed by doctors who are fully employed by the private clinic, and whose names are specified in the contract.
This avoids the possibility of a conflict of interest in which doctors from public health institutions, who participate in consultations that determine whether someone should go to a private clinic, would perform such examinations in private institutions through additional work.
The contract between Hippocrates and the Health Insurance Fund designates three radiologists and three medical technicians who can perform magnetic resonance imaging services.
One signature to the patient, the other to the Fund
The complaint filed by the Health Insurance Fund with the Police Directorate, which BIRN has seen, states that the Hippocrates Polyclinic did not provide accurate information in invoices for magnetic resonance imaging services. The contract stipulates that the private clinic must submit electronic and paper invoices on the services provided to the competent regional unit of the Health Insurance Fund once a month, and the invoice must be accompanied by a referral from the selected doctor, a proposal from the competent council of the Croatian Medical Council of Montenegro, and a report on the health services provided, with the signature and facsimile of the specialist doctor specified in the contract.
However, the HIF report states that during January and February of last year, Hippocrates submitted electronic invoices in which the chief radiologist was listed as a doctor who was only shown as a consultant in the reports, while the chief radiologist from the report was not listed in the invoices.
"The above indicates that the ordinarius (chief radiologist) was listed in the report only so that the invoice would be recognized by the HIF, and thus the funds would be paid to the institution, while in reality the service was provided by a doctor who was not covered by the contract," states the report signed by HIF director Vuk Kadić.
The application emphasizes that it is important that the report delivered to the patient must be identical to the report submitted to the Health Insurance Fund, warning that the invoice must authentically state the data from the specialist report.
"All of the above indicates that the reports were falsified so that they would be accepted through invoices and the funds would be paid," the report states.
Last November, the Health Insurance Fund submitted to the Police Directorate the magnetic resonance imaging examination reports of certain insured persons, which they submitted to the Health Insurance Fund as evidence in the process of exercising the right to temporary disability.
The report states that the patient reports were signed by Dr. Žanka Cerović, while the reports with the same protocol number and content that the polyclinic submitted to the Health Insurance Fund were signed by Cerović and the chief radiologist who is permanently employed at the polyclinic.
Žanka Cerović is the president of the Medical Chamber of Montenegro and is employed as a specialist radiologist at the KCCG, and until March 2023 she was the assistant director of the Clinical Center. In the contract between the HIF and Hippocrates, her name is not on the list of doctors who can examine patients whose costs are paid by the HIF.
The Health Insurance Fund reminded that according to the contract, costs are paid only if the scans are processed by a doctor who is in a full-time employment relationship with the private clinic.
"In this specific case, it is obvious that a fake report was submitted to the Health Insurance Fund, which is not credible and its content does not match the content of the copy submitted to the insured person, in order to exercise the right to payment for the said service from the Health Insurance Fund," the document states.
Cerović told BIRN that she works at Hipokrat as a consultant physician with the approval of her primary employer (KCCG) as part of her additional work, "as do most Montenegrin doctors, including the director of the Health Insurance Fund (Vuk Kadić)."
"I am convinced that all circumstances and facts regarding the case in question will be clarified through the competent legal procedure, and that the institutions of the system will act in accordance with the principles of objectivity, fairness and the presumption of innocence," said Cerović.
This is how she responded to BIRN's question about whether she was the chief radiologist on magnetic resonance imaging scans and, if so, whether she considers it moral and justified, given that she is also the president of the Medical Chamber and an employee of the Croatian Medical Association. She was also asked about the Health Insurance Fund's complaints about fake reports.
Cerović also said that she was unable to comment on whether the Hippocrates health institution committed the act that is the subject of a criminal report, since these facts will be determined by the competent authorities.
"However, as a long-time associate of this healthcare institution, I can confirm from my personal and professional experience that it is a respectable institution that has always demonstrated a high level of professionalism, responsibility and respect for the law," she said.
Despite several verbal promises, the Hippocrates polyclinic has not provided written answers to BIRN's questions about the Health Insurance Fund's application.
Debt for 2024 paid off through arbitration proceedings
The Health Insurance Fund told BIRN that after an arbitration process involving representatives of the polyclinic, the Ministry of Health, and the Medical Chamber, it was decided that the costs of Hippocrates' services for 2024 would be paid.
The contract between the HIF and the polyclinic stipulates that in the event of a dispute, an arbitration commission consisting of two representatives of the HIF and one representative each of the polyclinic, the Ministry of Health and the KCCG may be initiated, while a decision on the dispute must be made within 30 days.
"Based on the arbitration procedure, funds were paid for services that were actually provided in 2024, for which funds were allocated in the 2024 budget, while an investigation is underway before the Police Directorate regarding the falsification of documentation that enabled the unlawful acquisition of material benefit," the Health Insurance Fund stated.
The Health Insurance Fund said that, according to their accounting records, the amount of invoiced services from the Hippocrates polyclinic in 2024 amounted to 491.450 euros. They also pointed out that they expect the Police Directorate to determine whether and how many reports were falsified, stating that they will then be able to assess any potential damage. The Health Insurance Fund claims that after the report was filed, the Police Directorate did not contact them again on this matter, nor were any concrete decisions made.
The Police Directorate told BIRN that officers from the Criminal Police Station for Suppression of Economic Crime are acting upon a report from the Health Insurance Fund, stating that the necessary measures and actions are being taken upon the order of the Basic State Prosecutor's Office in Podgorica.
The Basic State Prosecutor's Office said that an order has been given to Police Directorate officers to collect the necessary information and to take all measures and actions provided for by law.
Tender for the procurement of magnetic resonance imaging equipment canceled again
The Capital Projects Administration launched a public procurement procedure at the end of 2022 for the procurement of two magnetic resonance imaging machines for the needs of general hospitals in Bijelo Polje and Nikšić, with an estimated value of 1,56 million euros excluding VAT. The procedure was never implemented, and after numerous appeals and several changes during the procedure, the final decision to cancel the tender was made in November 2024.
On June 6, the Ministry of Public Works announced a new tender for the procurement of magnetic resonance imaging (MRI) scanners for general hospitals in Bijelo Polje and Nikšić, worth 1,56 million euros, but cancelled it after only 10 days. The Commission for the implementation of the procedure decided that the technical specifications needed to be significantly changed after a certain number of requests for changes to the tender documentation were received.
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