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Honesty and integrity are required in dealings with third-party insurers

April 17, 2019
Lessons Learned: Licensees understand your responsibilities in operating your pharmacies.

A recent Hearing Tribunal issued its written decision on the merit and orders regarding the conduct of a pharmacist who was the owner, proprietor, and licensee of the Metro Pharmacy at 10608 97 Street NW in Edmonton during the period of the alleged misconduct. Central to the allegations considered were numerous concerns raised by a third-party insurer about claims submitted by the pharmacy that were later determined to have been falsified, dishonest, incomplete, without authorization, and/or without supporting purchase records. Additionally, throughout the investigation and hearing the pharmacist failed to cooperate with the college.

The Hearing Tribunal found that the pharmacist, as the licensee, was the person most responsible for the operation of the pharmacy, including the pharmacy’s submission of the audited claims to the third-party insurer, and the creation of the associated patient records. In doing so, the Hearing Tribunal found the pharmacist’s conduct was unprofessional and, as a licensee, she had engaged in serious misconduct. The Hearing Tribunal found that her actions had harmed the integrity of the profession and warranted serious sanctions. In this matter, the Tribunal imposed the most significant of penalties:

  • cancellation of the pharmacist’s registration;
  • fines totalling $50,000 (the maximum amount authorized under the Act);
  • the pharmacist not to be an owner, proprietor, or licensee of a pharmacy for a period of 10 years; and
  • payment of the full costs of the investigation and hearing. (Note that the costs shall in this matter shall total approximately $29,000).

Also, the Tribunal directed a copy of their decisions to be sent to the Minister of Justice and Solicitor General.

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

From the tribunal’s January 30, 2019, and April 4, 2019, decisions on merit and penalty, respectively:

Pharmacists are expected to conduct themselves with honesty and integrity and the submission of claims for products that were never provided to patients seriously undermines the integrity of the profession.

Maintaining accurate medical records is critical for patient safety and is a core competency expected of all pharmacists.

Members of a profession are expected and required to comply with requests from their College. This is an integral part of the College’s ability to self-regulate. The failure or refusal to comply with a College, seriously jeopardizes the College’s ability to protect the public and ensure the competence of its members and undermines the integrity of the profession.

There is no question that the conduct in this case on all allegations is far beyond the range of permitted conduct. There is a repeated pattern of dishonest interactions with an insurer, the creation of false dispensing records and the failure to comply with an investigation. [The pharmacist’s] conduct demonstrates an unwillingness to comply with the fundamental duties of a pharmacist and licensee as well as a complete disregard for the ethical duties and standards that apply to pharmacists and licensees.

Licensees – Incorporate these Lessons into Your Practice

  1. Review the Pharmacy and Drug Act , the Pharmacy and Drug Regulation and the Standards for the Operation of Licensed Pharmacies with regard to your responsibilities in the operation of your pharmacy.
  2. Review and discuss your obligations and the professional requirements of the pharmacy with your pharmacy’s owner and pharmacy staff to ensure that the pharmacy has the resources needed to meet these obligations.
  3. Don’t assume or “cut corners,” especially when creating patient records or submitting claims to third-party insurers. When in doubt, ask and confirm.
  4. Always approach your, and your pharmacy’s, contractual obligations with honesty and integrity.

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 be in the profession.