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Licensees: false assumptions about claim eligibility could be costly

November 16, 2022
Lessons Learned: Claims to third-party insurers must be honest and accurate.

Recently two Hearing Tribunals issued their written decisions on the merits and orders regarding the conduct of five pharmacists who were licensees at four different pharmacies during the period of the alleged unprofessional conduct and misconduct as follows:

Central to the allegations considered were the licensees’ submission of claims to a third-party insurer, when they should have known they were not entitled to the services claimed. Additionally, the licensees failed to create or maintain required and accurate pharmacy records.  

The Hearing Tribunals found the pharmacists’ conduct was unprofessional and, as the licensees, they had engaged in misconduct. The Hearing Tribunals found the actions of the licensees had the potential to undermine the integrity of the profession and decrease the public’s trust in the profession in their approach to submitting claims to Alberta Blue Cross, and warranted serious sanctions.

The Tribunals also noted that the pharmacists acknowledged and accepted responsibility for their conduct, undertook to improve their pharmacy’s operations, had no previous findings of unprofessional conduct, fully cooperated with the investigation, and made full restitution to the third-party insurer (totaling over $200,000).

In these matters, the Tribunals imposed significant penalties, even though the pharmacists admitted their responsibility for the allegations and acknowledged that they failed to exercise the professional and ethical conduct expected in their role as a pharmacist and licensee. The Tribunals ordered a range of sanctions, including

  • Suspensions for each pharmacist ranging from three months to seven months. Each pharmacist is to serve at least one month of their suspension, with the remainder held in abeyance pending completion of other orders. Note that each of them has already served their suspension or the dates of the practice suspension have been scheduled.
  • The successful completion of Parts A & B of the ACP Licensee Education Program by each of the five pharmacists.
  • The unconditional passing of the Center for Personalized Education for Professionals (CPEP) Probe Ethics and Boundaries Course by two of the pharmacists.
  • An additional period of suspension to be imposed on two of the pharmacists should they not complete the LEP and Probe Course within 12 months of the written decision.
  • Fines for each of the pharmacists from between $5,000 and $10,000. The combined total fines ordered was $40,000.
  • All five pharmacists to provide a copy of their written decisions to their employers or licensees of any pharmacies where they work as a pharmacist for three years after receiving the written decision.
  • If the complaints director refers similar concerns to a Hearing Tribunal within five years, he may direct that the pharmacist cannot serve as an owner, proprietor, or licensee of a pharmacy for a period of three years.
  • The pharmacists must pay 100 per cent of the costs of the investigations and hearings (estimated to be approximately $129,400).

Rationale for the Tribunals’ decisions is reflected in the following statements resulting from the June 14, 2022, hearing:

[The pharmacist] failed to attain an adequate understanding of the eligibility and limitations of the claims submitted to ABC for professional services. Furthermore, it was [the pharmacist’s] responsibility to understand how each professional service could be submitted legitimately. [The pharmacist] relied simply on the adjudication result by ABC for her submission. The ABC adjudication message was never intended to “validate” submissions. This “short cut” is inadequate in the view of the Hearing Tribunal. Information is readily available to all pharmacists in the Alberta Blue Cross Pharmacy Agreement and the Pharmacy Benefacts. The public expects pharmacists to have complete and up-to-date knowledge about the appropriate submission of claims for professional services. Furthermore, the self-regulatory nature of the profession relies upon this.

… … …

 The public must have the confidence that pharmacists maintain accurate and complete records at all times. The potential for serious health consequences is significantly heightened in the absence of this.

… … …

The public relies on regulated members of the pharmacy profession to know and abide by its legislation and standards. The failure to do so undermines public confidence in the profession and harms the integrity of the profession in the public’s eyes.

Licensees, pharmacists, and pharmacy technicians – 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 when operating a pharmacy.
  2. Complete Parts A and B of the ACP Licensee Education Program (LEP) to learn more about the duties and responsibilities of a licensee.
  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. As a licensee, when you take over the operations, workflow practices, and billing practices of an existing pharmacy, don’t assume that the pharmacy is fully compliant with all its obligations and requirements. As the licensee, you are personally responsible for ensuring compliance.
  4. Don’t assume that just because an electronically submitted claim is not rejected, that you are in full compliance with your third-party agreement. 
  5. Keep current with the contractual requirements pertinent to your pharmacy’s third-party insurer agreements. Carefully review the contract to ensure you are in compliance. Don’t guess when submitting claims for drugs, healthcare products, and pharmacy services. Many third-party insures publish periodic interpretation and guidance documents, such as the Alberta Blue Cross Compliance Verification Benefact updates. As a licensee, you are responsible to clearly understand and comply with the requirements and restrictions of all third-party insurer agreements that your pharmacy submits claims to. This responsibility extends to the claims submitted by all your pharmacy team members.
  6. 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 ethically, professionally, and with integrity.
  7. Ensure that all required pharmacy records are complete and can be retrieved in an efficient, systematic manner. 
  8. Licensees: ensure all pharmacy team members that submit claims understand and comply with the contractual requirements.
  9. Pharmacists and pharmacy technicians: you are responsible for the claims you submit on behalf of your patients.

*This article was updated on November 17, 2022, to correct details about the length of suspensions ordered.