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Pharmacist suspended for unsupported third-party insurance claims

September 16, 2020
Lessons Learned: supply records must by kept and only safe and proven suppliers must be used.

A recent Hearing Tribunal issued its written decision on the merit and orders regarding the conduct of a pharmacist who was a pharmacy’s owner, proprietor, and licensee during the period of the alleged unprofessional conduct. Central to the allegations considered were concerns raised by a third-party insurer about inventory documentation and other claim-supporting records submitted by the pharmacy. A third-party insurer’s audit of the pharmacy’s claims for a 32-month period led to a complaint of professional misconduct, an Alberta College of Pharmacy (ACP) investigation, and referral to a Hearing Tribunal. The Tribunal determined that the pharmacist:

  • submitted approximately $1.5 million dollars worth of claims for health care products (such as Ensure and Pediasure) without being able to provide the required supplier invoices;
  • failed to properly create or retain required and accurate pharmacy records;
  • submitted claims for health care products that he did not have the stock to provide to patients and thus submitted false claims and created inaccurate dispensing records for the patients;
  • purchased and dispensed health care products from suppliers that were not safe or proven;
  • purchased and dispensed health care products he knew, or should have known, had been previously dispensed by another pharmacy and were then resold to him; and
  • failed to act ethically or honestly in his dealings with a third-party insurer.

In doing so, the Hearing Tribunal found the pharmacist’s conduct was unprofessional and as a licensee he had engaged in misconduct. The Hearing Tribunal found that his actions had created the potential for patient harm, harmed the integrity of the profession and warranted serious sanctions.

The Tribunal also noted that the pharmacist was remorseful and accepted responsibility for his conduct, had no previous findings of unprofessional conduct, fully cooperated with the investigation, and undertook to make full restitution to the third-party insurer (approximately $1.5 million dollars).

The Tribunal ordered the following penalties:

  • a three-year suspension;
  • after serving his suspension, and prior to being eligible to reinstate as a clinical pharmacist, the pharmacist must successfully complete
    • the Centre for Personalized Education for Professional’s Probe Course, and
    • the ACP’s Ethics and Jurisprudence Exam;
  • after completing the Probe Course and ACP Exam, and upon reinstating as a clinical pharmacist, the pharmacist’s practice permit shall be subject to the conditions that
    • he practises under direct supervision for six months, and
    • for an additional six months, the licensee of any pharmacy in which the pharmacist is employed shall provide a report to the Complaints Director on a monthly basis;
  • the pharmacist not to be an owner, proprietor, or licensee of a pharmacy for a period of 10 years;
  • total fines of $40,000;
  • payment of the total costs of the investigation and hearing (estimated to be $37,000); and
  • the pharmacist must provide a copy of the written decision to the proprietor and licensee of any pharmacy where he applies to work or works as a pharmacist for five years, commencing on the date he receives a copy of the Tribunal’s written decision and continuing for five years after he reinstates as a clinical pharmacist.

Towards the end of the ACP investigation, the pharmacist’s pharmacy permanently closed on June 24, 2019, and his agreement with the third-party insurer was cancelled.

Rationale for the Tribunal’s decision, is reflected in its following statements from the August 10, 2020 decision:

The public should be entitled to expect pharmacists to be honest in their dealings with others in the provision of healthcare services. The public should also be entitled to expect that pharmacists will not allow their own financial interests to take precedence over their professional obligations and judgment.

(The pharmacist) failed to demonstrate the ethical conduct and professional judgment expected and required of an Alberta pharmacist and pharmacy licensee; this failure created the potential for patient harm since product was procured from unverified sources and in cases knowingly, or should have known that, dispensed product was originally provided to other patients. It decreases the public and insurer’s trust in the profession for the reason that (the pharmacist) felt it was acceptable to go outside of the standards established precisely in place to protect the public.

This was a case about basic ethical expectations and all regulated members are expected to conduct themselves appropriately, with integrity and in compliance with the law at all times, regardless of their degree of experience or seniority.

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 when operating a pharmacy.
  2. Don’t assume or “cut corners,” especially when creating patient records or submitting claims to third-party insurers. When in doubt, ask and confirm.
  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 required pharmacy records are maintained in an authorized location and can be retrieved in an efficient, systematic manner.
  6. ONLY obtain and provide drugs, non-prescription medications, and health-related products from safe and proven sources, such as licensed and regulated drug manufacturers and wholesalers.
  7. NEVER obtain and provide products from unlicensed and unregulated sources.