Frequently Asked Questions
- What is the Kansas Department of Health and Environment Office of Inspector General (KDHE OIG)?
- What programs and operations does the DHCF administer that could be subject to OIG oversight?
- Who is the Inspector General?
- What is the mission of the OIG?
- How does the OIG perform its work?
- What happens to the results of OIG audits and investigations?
- How is the KDHE OIG able to provide increased accountability in DHCF’s programs and operations?
- How is the KDHE OIG able to provide increased integrity in DHCF’s programs and operations?
- Does the OIG have access to confidential records, including medical records, in performing its work?
- Are there any protections for whistleblowers who wish to report illegal or otherwise questionable acts to the OIG?
- What is fraud?
- What is waste?
- What is abuse?
- What happens if the OIG finds evidence of fraud, waste, abuse or other illegal acts?
- How do I contact the OIG with my concerns?
- 16. Are there other places that I can contact with concerns about DHCF programs, including KanCare (formerly Medicaid, MediKan, and HealthWave) and the State Employees Health Benefits Plan?
- What if I have an issue with Medicare?
- What other websites would be helpful to learn more?
The Kansas Health Policy Authority Office of Inspector General (OIG) was created in 2007 by the Kansas Legislature as an independent oversight body. The KHPA OIG was the first statutorily-created Office of Inspector General in the state of Kansas. The OIG enabling legislation can be found in Kansas Statutes Annotated (K.S.A.) 75-7427. On July 1, 2011, the Kansas Health Policy Authority became the Division of Health Care Finance (DHCF) within the Kansas Department of Health and Environment.
In general, the OIG’s function is to review and help improve DHCF programs and operations and to investigate, identify and deter fraud, waste, abuse and other illegal acts in KanCare (formerly the Medicaid and MediKan programs, as well as HealthWave, the State Children’s Health Insurance Program).
As indicated in KSA 2005 Supp.75-7401, et seq., the mission of the Division of Health Care Finance (DHCF) is to develop and maintain a coordinated health policy agenda which combines the effective purchasing and administration of health care while promoting effective public health strategies. The powers, duties and functions of the Division of Health Care Finance are intended to improve the health of the people of Kansas by increasing the quality, efficiency and effectiveness of health services and public health programs. To fulfill its mission, DHCF manages KanCare (the State Medicaid program), the State Employees Health Benefit Plan, and the State Self-Insurance Fund for Workers’ Compensation.
The current Inspector General is Bill Gale.
- To provide increased accountability and integrity in the Division of Health Care Finance’s programs and operations.
- To help improve those programs and operations.
- To identify and deter fraud, waste, abuse and other illegal acts.
The OIG accomplishes its mission through audits, investigations and reviews.
The OIG pursues three different types of activities to meet its mission: audits, investigations and reviews.
- Audits (including performance and financial audits) - In general, audits are formal evaluations of an organization, its systems, processes, projects or products. Performance audits examine the effectiveness or efficiency of a program or operation. Financial audits review either financial documents to verify their accuracy, or internal processes, usually related to handling money, to review their strength. The overarching goal of all OIG audits is to review the quality of DHCF programs and processes and make recommendations for improving them. The OIG conducts its audits in a manner consistent with generally accepted government auditing standards developed by the U.S. Government Accountability Office (GAO). These standards are also commonly known as The Yellow Book. Audit topics are identified through an annual risk assessment resulting in the development of an annual audit plan.
- Investigations - Investigations are inquiries into specific circumstances surrounding an allegation or incident of fraud, waste, abuse or other illegal act. They attempt to determine the extent of the incident, the amount of loss, and what weaknesses may have existed that lead to the allegation/incident. Investigative reports may make corrective action recommendations intended to avoid similar problems in the future. The OIG will conduct investigations that are consistent with the principles and quality standards set out for investigations by the Association of Inspectors General (AIG). Topics for OIG investigations will be identified by audit work performed by OIG staff as well as referrals from DHCF staff, legislators, and the general public.
- Reviews - Reviews, which may also be called inspections or evaluations, are inquiries into a specific programmatic aspect of DHCF’s operations. Reviews may attempt to determine many issues, such as whether a component of the program is effective and efficient or whether the program component has good strategies to safeguard the appropriate use of state funds. Like investigations, the OIG will conduct reviews that are consistent with the principles and quality standards set out for inspections, evaluations and reviews by the Association of Inspectors General (AIG). Topics for OIG reviews will be identified by audit work performed by OIG staff as well as referrals from DHCF staff, legislators, and the general public.
Copies of the final audit reports are provided to the KDHE OIG Audit Committee, KDHE Secretary, DHCF management and are posted on the KDHE OIG website. In addition, the Inspector General will provide an annual report summarizing the OIG’s activities during the past year. Copies are provided to the Governor, several legislative committees, and the Legislative Post Auditor.
Accountability is an ethical concept that relates to decision-makers being held responsible for their “actions, products, decisions, and policies, including the administration, governance and implementation within the scope of the role or employment position and encompassing the obligation to report, explain and be answerable for resulting consequences.”
The KDHE OIG provides increased accountability by examining DHCF’s decision-making processes, and reporting subsequent findings to the public. Furthermore, based on its review, the KDHE OIG will make recommendations for improving DHCF programs and operations to help DHCF meet its mission.
Program integrity is the concept of using public funds appropriately. Methods for promoting program integrity include implementing procedures to ensure that public funds are spent efficiently for program needs and reducing fraud, waste and abuse. The DHCF OIG will provide increased program integrity by performing objective reviews to ensure public funds are spent appropriately and that procedures have been put in place to support agency integrity. Furthermore, based on its review, the DHCF OIG will be able to make suggestions for improving integrity in DHCF programs and operations and helping DHCF to meet its mission.
The controlling statute states that staff may have access to all pertinent information necessary, confidential or otherwise, to carry out the duties of the OIG. This includes information maintained by DHCF staff, vendors, contractors, health care providers and federal, state and local government agencies.
However, there are some limits on the OIG’s access to confidential records. Access is limited to those files maintained by providers or contractors only to the point necessary to verify the accuracy of invoices, compliance with contract provisions, or compliance with program requirements. Furthermore, the OIG may not access any medical records related to individuals who are not enrolled in Medicaid or other DHCF programs.
In addition, OIG staff is subject to a strict code of confidentiality and consequences for violation of that public trust. To maintain record confidentiality, the OIG statute makes OIG staff subject to the same duty of confidentiality imposed by law on any other person or agency from whom it receives the information. For example, if OIG staff obtains medical records deemed confidential under the federal Health Insurance Portability and Accountability Act (HIPAA), staff is required to maintain that confidentiality.
There is an exception to the confidentiality clause when OIG staff identifies evidence of fraud, waste, abuse, or other illegal acts. In that case, the OIG has the additional responsibility of preserving the evidence and immediately notifying the Office of the Kansas Attorney General for possible criminal or administrative action. At that point, the OIG turns the case over to the Attorney General.
For more information, see FAQ #14: What happens if the OIG finds evidence of fraud, waste, abuse or other illegal acts?
10. Are there any protections for whistleblowers who wish to report illegal or otherwise questionable acts to the OIG?
There are several types of protections for people reporting information to the OIG on fraud, waste, abuse or other illegal acts in the programs administered by DHCF.
First, the OIG may not make public the identity of a whistleblower, unless that person consents to the disclosure in writing.
Second, the information provided remains confidential and may only be made public if one of following four conditions exists:
- The release of information is required to protect the public health.
- The whistleblower consents to the release of information.
- The whistleblower’s identity will continue to remain confidential even with the release of information.
- The information is required to be disclosed in an administrative proceeding or court proceeding, and the identity of the whistleblower can continue to be protected.
Third, the OIG statute prevents any person from prohibiting their agents, employees, contractors or subcontractors from making a report to the OIG. Additionally, the statute prevents any person from requiring their agents, employees, contractors, or subcontractors to give notice prior to reporting to the OIG.
Fourth, if a whistleblower believes he or she has been retaliated against by his or her employer for reporting to the OIG, he or she may bring an action in court to collect damages for the retaliation. Finally, if the whistleblower is a state employee, he or she gains all the protections found in the Kansas Whistleblower Act, K.S.A. 75-2973.
Fraud is an illegal act that involves the intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. Some examples of fraud that have the potential to occur in DHCF programs are:
- A beneficiary misrepresenting his or her income and assets in order to qualify for Medicaid.
- A provider billing for services that were not provided.
- A doctor illegally dispensing controlled substances.
Waste is the intentional or unintentional, thoughtless or careless expenditure, consumption, mismanagement, use, or squandering of state resources. Waste also includes incurring unnecessary costs as a result of inefficient or ineffective practices, systems, or controls.
Examples of waste that have the potential to occur in DHCF programs include:
- A beneficiary goes to his or her doctor for excessive and unnecessary check-ups.
- A provider recommends and bills Medicaid for extra medical tests beyond what is truly necessary.
- An employee allows overpayments to a contractor by not checking that services were actually performed.
Abuse is an excessive or improper use of authority in a manner contrary to the natural or legal or ethical rules for the use of that authority.
Examples of abuse that have the potential to occur in DHCF programs include:
- A beneficiary applies to participate in the Medicaid programs in both Kansas and Missouri and proceeds to get medical attention in both states.
- A provider prescribes and bills Medicaid for medicines that a beneficiary does not really need.
- An employee suggests that DHCF award a contract to a business that is owned by the employee’s friend.
This office will also investigate concerns about abuse and neglect of a patient in any health care facility receiving Medicaid funds.
By statute, the Inspector General is required to report any findings of credible evidence of fraud, waste, abuse or other illegal acts to the Kansas Attorney General. Furthermore, the OIG will work closely with the Attorney General to ensure that appropriate law enforcement agencies are able to take over the case from the OIG.
If the OIG determines that reasonable suspicion exists that a licensed or otherwise regulated entity, such as a nurse or physician, may have violated their licensure or other regulatory standards, the Inspector General is required to report such suspicions to the appropriate regulatory agency.
The OIG can be reached by phone at 785-296-1076 or by e-mail at OIG@kdheks.gov.
The DHCF has set up the following phone numbers for questions about their programs.
- For questions about Medicaid, MediKan and HealthWave, call 785-296-3981.
- For questions about the State Employee Health Plan, call 785-368-6361.
- For questions about the State Self Insurance Fund for Workers’ Compensation, call 785-296-6995.
- For concerns about fraud perpetrated by a Medicaid provider, contact KDHE OIG at 785-296-1076 or the Kansas Attorney General’s Office, Medicaid Fraud and Abuse Division at (toll free) 1-866-551-6220 or 785-368-6220.
Medicare is a federal health insurance program that covers individuals 65 and older, individuals under 65 with disabilities, and individuals with End Stage Renal Disease (ESRD). Neither the DHCF nor the OIG have any authority over the Medicare program; however, for concerns or questions about the Medicare program, call Senior Health Insurance Counseling for Kansas (SHICK) at 1-800-860-5260 or the federal Medicare program at 1-800-MEDICARE (1-800-633-4227).
State agency sites:
Department for Children and Families |
Kansas Department for Aging and Disability Services |
Juvenile Justice Authority |
Kansas Attorney General |
Kansas Attorney General, Medicaid Fraud and Abuse Division |
Kansas Legislature |
Kansas Legislative Division of Post Audit |
Federal agency sites:
Association of Inspectors General |
Association of Certified Fraud Examiners |
Association of Government Accountants |
Association of Government Accountants, Topeka Chapter |
Institute of Internal Auditors |
Institute of Internal Auditors, Topeka Chapter