July • August 2003 - Ontario College of Pharmacists

COMPLAINTS
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Altering Third Party
Payor Information
Acting Outside the Scope of the Pharmacist’s Role
Eva Markowski, Complaints Officer
The College frequently receives complaints from
third-party payors about situations in which
pharmacists acted outside their professional scope of
practice by altering coverage data to assist patients
in the processing of a claim. This article examines
such a complaint and the Complaints Committee
investigation and disposition.
Facts
A man attended a pharmacy and
presented a third-party insurer card for
two prescriptions. Upon entering information
into the computer the
pharmacist saw that, while the patient
was not covered, the patient’s spouse
was insured under the policy number.
The patient insisted that he was
covered and the pharmacist attempted
twice more to process the transaction.
Both attempts failed. A fourth attempt
succeeded but only after the pharmacist
altered the patient’s profile to
indicate that he was the cardholder,
rather than the spouse. The pharmacist
then entered the cardholder’s date
of birth.
Although the patient received
coverage under the plan, a few days
later, the pharmacist’s alterations to the
profile resulted in these transactions
being assigned to the cardholder, not
the patient. Documentation substantiating
the transaction was provided to
the College by the third party insurer.
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Pharmacy Connection July • August 2003