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Honesty is required in dealings with third-party insurers

May 13, 2020

Lessons Learned: Pharmacists must not manipulate drug benefit claims to insurers or other payors for their own benefit or for the benefit of individual patients.

A recent Hearing Tribunal issued its written decisions on the merit and orders about the conduct of a pharmacist who was a pharmacy’s owner, proprietor, and licensee during the period of the alleged unprofessional conduct. A third-party insurer’s audit of the pharmacy’s claims for an eight-month period led to a complaint about professional misconduct, an Alberta College of Pharmacy (ACP) investigation, and referral to a Hearing Tribunal that determined that the pharmacy

  • submitted claims without being able to provide the required supplier invoices;
  • submitted claims when the pharmacy was not entitled to the number of dispensing fees claimed;
  • submitted claims for services and drugs that were not provided to the patient, and the claims and dispensing records were not properly reversed and corrected;
  • created patient dispensing records for drugs that the pharmacy knew were not received and thus not used by the patient;
  • failed to act ethically or honestly in its dealings with a third-party insurer; and
  • failed to properly create or retain required and accurate pharmacy records.

The Tribunal ordered the following:

  • a reprimand;
  • $8,500 in fines;
  • a condition that the pharmacist shall not serve as a licensee, pharmacy owner, or proprietor for a period of two years and the pharmacist must pass ACP’s Ethics & Jurisprudence exam before being eligible to return as a licensee, pharmacy owner, or proprietor; and
  • the costs of the investigation and hearing to a maximum of $30,000.

In addition, the pharmacy paid the third-party insurer the money the audit determined was owed. The timely repayment by the pharmacy was considered by the Hearing Tribunal in its decision on sanctions.

Rationale for the Tribunal’s decision, is reflected in its following statements:

While it may be common practice to borrow or purchase stock from other pharmacies, and while collegial relationships exist between neighbouring pharmacies in an attempt not to fragment patient care, pharmacies and licensed members of the College have a regulatory obligation to keep accurate records surrounding the purchase or sale of every Schedule 1 and 2 drug product.

An important part of preserving the integrity of the profession is behaving ethically in submitting accurate claims to insurers. There are billions of dollars paid by public and private insurers based on electronic claim receipts from pharmacies, and insurers trust the integrity of the pharmacy and the integrity of the information they receive to be true and they pay these claims in good faith and trust in the profession. It is essential that all insurers be able to rely on the integrity of the pharmacist/pharmacy and the assurance that the information in the transaction records that are being provided is accurate.

The public is entitled to expect that pharmacists will not manipulate drug benefit claims to insurers or other payors for their own benefit or for the benefit of individual patients.

The public is entitled to expect that pharmacists will only bill insurers and other payors for dispensing drugs that are actually delivered to the patient directly or indirectly through an agent.

If the pharmacist has submitted a claim to ABC for dispensing the drug but the plan member does not pick-up the drug and the drug is not delivered to the plan member within 30 days of the pharmacist making the drug available, then the pharmacist must reverse the claim to ABC.

Section 1.2(a) [of the ABC pharmacy agreement] is not ambiguous. It creates an obligation on providers like [the pharmacy] to submit claims to ABC within 14 days of the date on which a pharmaceutical service is provided, or made available to the plan member, whichever is earlier.

It should be made clear to the profession that there is no financial benefit for submitting inaccurate claims or in omitting to reverse claims when drugs are not actually dispensed in the manner that they are claimed.

Appropriate record keeping goes to the heart of the integrity of the profession. There must be confidence that the information submitted to insurers is truthful and accurate. It is a serious matter to make pharmacy claims without invoices and without the ability to trace your pharmacy supply. The conduct in question harms the integrity of the profession.

Pharmacists, pharmacy technicians, and licensees – review your ethical duties to our profession and yourself

  1. Licensees, review the Pharmacy and Drug Act, the Pharmacy and Drug Regulation and the Standards for the Operation of Licensed Pharmacies regarding your responsibilities when operating a pharmacy
  2. Review and discuss your obligations and the professional requirements of the pharmacy with the pharmacy owner, licensee, and staff to ensure that the pharmacy has the resources needed to meet these obligations.
  3. Review and consider your ethical responsibilities outlined in Principles 1 and 10 of the Code of Ethics. Always approach your, and your pharmacy’s, contractual obligations with honesty and integrity. 
  4. Ensure that all required pharmacy records are created and maintained, including the receipt of drugs and health care products from ALL suppliers.
  5. Ensure that all records of dispensing events uploaded onto Netcare are accurate.
  6. Don’t assume or “cut corners,” especially when creating or maintaining patient records or submitting claims to third-party insurers. When in doubt, ask and confirm.

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