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