Healthy + Medication + Fraud
In April, we feature Toni Prine, RPh, CP, CIG, AHFI (Senior Manager, Atlanta). She shares her perspective about her previous role as a program integrity employee with Georgia Medicaid and her current role at Myers and Stauffer.
“The mission statement I worked under as a program integrity employee with the Medicaid agency in Georgia was:
‘We have a responsibility for the health and well-being of our members and a fiduciary responsibility to the taxpayers.’
I believed the statement was true then and still believe it is true today.
I was involved in a case where a pharmacy provider was overbilling on medications for infants. The provider was not physically harming them, but he was overcharging Medicaid – taking more money than he should have for his own personal gain. He falsified the amounts used and then billed for more than was administered to patients. This provider was selfish and getting more money than he was entitled to just to enrich himself.
This case mattered to me because the patients were preemie babies, and I was the mother of preemie baby twins. Twenty years ago, my son was in the hospital and needed those same medications to treat RSV. Anyone can contract RSV, but for preemies or kids with congenital issues, it can be particularly dangerous. One of the main reasons my son got RSV is because he was so small, and his system could not fight it off. The medication is vital to that patient population.
Taxpayers and tax dollars pay for Medicaid. Providers such as this one are typically driven by greed, while justifying their actions by saying they are underpaid. Meanwhile, costs and premiums continue to rise to cover the losses incurred. Ultimately, this makes for fewer resources available to those who really need them.
Our goal is to ensure there are sufficient dollars available so that more members can receive services provided in compliance with payer guidelines. The goal is not to create systems that make reimbursement for services difficult. If we do our jobs well, providers, health plans, and health care vendors can continue to serve our community – and members will have continued access to services they need.” – Toni Prine
Get to Know Toni
Using her extensive background in the state of Georgia Medicaid program, Toni serves as a subject matter expert for the firm. She leverages her knowledge of policy development, enforcement, and governance to provide clients with thought leadership and cutting-edge fraud, waste, and abuse detection methods. Her background with Georgia Medicaid also makes her well versed in the oversight of managed care organizations. Additionally, Toni draws from her background as a pharmacist to support clients in payment integrity related to their respective Medicaid RX programs. Her ability to know and understand issues from the government perspective allows her to help clients navigate the ever-changing state regulatory and compliance landscapes.
Myers and Stauffer is proud to help our clients serve those who are most vulnerable. Our staff feel empowered to know that their hard work and dedication each day makes a difference. We believe it and so do the millions of individuals helped by the clients we serve. We will release new stories each month highlighting associates and their stories. Follow along with our LinkedIn, Twitter, and Instagram for more information.