Cooperating with a college investigation or insurer audit is a must

A recent Hearing Tribunal issued its written decisions on the merits and sanctions regarding a pharmacist who was also the pharmacy’s owner and licensee. Allegations were raised that the pharmacist failed to properly cooperate with an insurer audit when he refused to provide relevant information and documentation about prescription claims. Allegations were also raised about the pharmacist unacceptably dispensing drugs and medical devices to themselves or their immediate family, and, at times, in the absence of a documented corresponding medical indication. During the investigation, the pharmacist then failed to cooperate with the Alberta College of Pharmacy’s (ACP) investigator, resulting in an additional allegation of unprofessional conduct.

The Hearing Tribunal found that, as a pharmacist and licensee, he acted unethically and inappropriately when he failed to cooperate and when he provided medications to himself and his family members. The panel expressed grave concerns with his failure to cooperate, pronouncing this type of conduct as indicative of being ungovernable. The Hearing Tribunal found the pharmacist’s conduct was unprofessional and, as a licensee, he had engaged in misconduct. The Hearing Tribunal found that he failed to demonstrate the ethical conduct and professional judgement required of an Alberta pharmacist and pharmacy licensee, his actions undermined the integrity of the profession, and warranted significant sanctions.

In this matter, the Tribunal prescribed the following sanctions (amongst the most significant available):

• the pharmacist’s registration with ACP was cancelled (note the pharmacist has not held an active practice permit since June 30, 2023);
• fines totaling $30,000 to be paid within 90 days;
• a prohibition on the pharmacist serving as a pharmacy licensee, proprietor, or owner for 10 years (note that the pharmacist’s pharmacy was permanently closed on May 23, 2023); and
• the pharmacist to pay 100 per cent of the costs of the investigation and hearing (note that the costs are $32,952).

Rationale for the Tribunal’s decision is reflected in the following statements from its May 8, 2024, sanctions decision:

The Hearing Tribunal finds that this is a case involving two very serious aspects of unprofessional conduct: 1) a pharmacist dispensing supplies and medications to themselves and family members when not appropriate and 2) a failure to cooperate in an investigation and insurer audit. The conduct involves dishonest conduct by the member, which benefitted him financially and seriously undermines the integrity of the profession. Members of the public rely on insurance to pay for their prescriptions and the health care system relies on the honesty and integrity of the self-regulated professionals within it to submit claims on their behalf. [The pharmacist] failed to meet these obligations of honesty and integrity.

In addition, [the pharmacist’s] failure or refusal to cooperate in the investigation, after refusing to cooperate with [the insurer’s] audit, raises a concern with respect to the College’s ability to regulate him as a member. In failing to cooperate with the investigation, [the pharmacist] demonstrated a blatant disregard for the self-regulatory nature of the profession. If a college is unable to regulate its members, its ability to act as a self-regulating profession is placed in jeopardy.

… … …

[The pharmacist’s] response to the complaints and the College’s investigations was egregious. He tried to mislead the investigator as to the relationship between himself and patients and failed to address the questions, repeatedly stating that he was not “prepared to respond” or “not ready” to answer questions. [The pharmacist] was given multiple opportunities to provide the requested information but failed to do so. This is conduct that is similar to [the pharmacist’s] response to [the insurer] and its auditor, where [the pharmacist] provided only limited documentation and refused to provide additional information, prior to ceasing to respond altogether. 

 Incorporate these lessons into your practice

1. Understand that a failure or refusal to cooperate with a practice visit, inspector, investigator, or field officer may be considered unprofessional conduct or misconduct. See section 1(1)(pp) of the Health Professions Act and sections 1(1)(p) and 21(8) of the Pharmacy and Drug Act. As a pharmacy professional, if you are not willing to comply with a request of an investigator, ACP must consider whether you can be regulated, and thus whether you should remain on the register. 
2. Review, consider, and understand your ethical responsibilities outlined in Principle 3.4, 10.1, 10.2, and 10.10 of the Code of Ethics. Providing treatments—such as prescribing, dispensing, or injecting—for yourself or family must only occur within the very limited exceptions outlined in the Code. Standard 1.22 of the Standards of Practice for Pharmacists and Pharmacy Technicians provides prescribing restrictions that pharmacists must also comply with.
3. Ensure that all required pharmacy records are created, maintained, and can be retrieved in an efficient, systematic manner.
4. Always approach your, and your pharmacy’s, contractual obligations with honesty and integrity.
5. Keep current with the contractual obligations pertinent to your pharmacy’s third-party insurer agreements. Understand and comply with authorized requests for information and documentation.
6. Take responsibility in preparing for, and participating in, third-party insurer audits. Have sufficient staffing available to properly respond to the audit requirements in a fulsome and timely manner.
7. Review the Pharmacy and Drug Act and the Standards for the Operation of Licensed Pharmacies with regard to your responsibilities when operating a pharmacy.
8. Complete Parts A and B of the ACP Licensee Education Program (LEP) to learn more about the duties and responsibilities of a licensee and review ACP’s professionalism resources.