Missouri’s Conflict-Free Case Management
Strategies
Missouri has federal authority in five 1915(c) Home and Community-based waivers targeting individuals
with developmental disabilities and also has authority through an approved Medicaid State Plan under
1915(g) for the delegation of case management functions to non-state entities. The five waivers are:

Missouri DD Comprehensive Waiver, base number MO 0178

Missouri DD Community Support Waiver, base number MO 0404

Missouri Children with DD waiver, base number 40185

Missouri Autism Waiver, base number 0698

Missouri Partnership for Hope Waiver, base number 0841
“Targeted” case management (TCM) functions managed by DMH may be provided by a variety of
entities: the DMH Regional Offices, county-based Senate Bill 40 Boards, or other not-for-profit agencies
designated by DMH/DD. Currently safeguards are in place to ensure the case manager does not restrict
an individual’s free choice of case manager or service providers because these entities may also provide
direct services.
Missouri law explicitly requires the Department of Mental Health’s Division of Comprehensive
Psychiatric Services to designate entry points into the public mental health system.
The division shall identify community-based services in each geographic area as entry and exit points into
and from the state mental health delivery system offering a continuum of comprehensive mental health
services. [RSMo 632.050]
Those entry/exit points are the department’s administrative agents. Administrative agents are
community mental health centers (CMHCs) designated in each service area to provide a comprehensive
array of mental health services.
Safeguards against conflicts in case management include:
1. The division’s Billing and Services Review Unit (BSR) conducts yearly reviews of client records to
assure that paid services are clinically appropriate, tied to the treatment plan, and delivered by
qualified staff.
2. The division has a Certification Unit which certifies providers that meet all required standards. In
addition, all CMHC’s are either currently accredited by a national accrediting body such as CARF
or The Joint Commission, or are working toward such accreditation. Between certification
surveys, annual Safety and Basic Assurance visits are conducted to review core certification and
contract compliance.
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3. The division has a strong collaborative relationship with the state Medicaid agency that has
resulted in several key projects important to the integration of physical and behavioral health,
ensuring a more comprehensive treatment approach:
a. DMH Net Behavioral Pharmacy Management Program helps improve prescribing
practices to those with SMI, and reduces unnecessary spending on psychotropic
medications.
b. The Disease Management 3700 Project (DM 3700) was developed to provide outreach
and engagement to individuals with SMI and high Medicaid costs who were not
receiving mental health services. DM 3700 provides care coordination between mental
health and physical healthcare providers. The program saved the state $9.2 million in
the first 12 months.
c. CMHC Health Homes employ a whole person approach to healthcare. Health Homes
coordinate and provide access to health services, preventive and health promotion
services, and mental health and substance abuse services. Health Homes use data
analytic tracking and comprehensive care management tools to assure that health care
needs are adequately and appropriately addressed. Disease management reports
monitor 14 performance indicators related to the treatment and management of
chronic illness.
4. State law requires that the division have an advisory council, with at least half the members
being persons served, to advise the division on policies, services, and program development
affecting consumers and the quality of care they receive (RSMo 632.020).
5. The department operates a statewide consumer complaint system that gives individuals another
method of reporting complaints with services and violations of their rights.
6. The DMH Audit Unit investigates claims of improper accounting or business practices.
The department holds a contract with each administrative agent that, among other things, requires
compliance with certification standards that mitigate the potential for conflict in case management.
They include:
1. Each person served must directly participate in the development, review, and revision of an
individualized treatment plan.
2. The CMHC must have policies to prevent staff from entering into dual or conflicting relationships
with persons served that might affect professional judgment or increase the risk of exploitation.
3. The CMHC must participate in a state system that reports, tracks, and investigates allegations of
client abuse and neglect.
4. The CMHC must have a grievance system that includes an impartial review of complaints and
grievances related to quality of care and violation of client rights.
5. Qualified staff must meet appropriate credentialing and educational requirements.
Service coordination to develop individual service plans and to arrange for and conduct ongoing
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monitoring of services is an integral component in all service delivery in Missouri. Entities that have
responsibility for service plan development sometimes also provide direct services. Individuals have the
right to request a different provider to develop the service plan. However, when an entity provides
direct services and has responsibility for service plan development, all quality management functions
and actions are applicable.
Quality management functions performed by the local TCM entity include record reviews to validate the
following requirements have been met:
1. Evidence that case management staff meet qualifications
2. Records are maintained for each individual receiving support coordination
3. Annual Individual Support Plan (ISP) is prepared according to these guidelines:
a. ISP supports waiver services that are prior authorized
b. Service authorizations accurately reflect support plan and budget
c. ISPs are updated/reviewed at least annually with required components, or when
warranted by changes in the individual’s needs
d. Provider monthly reviews and Support Coordinator quarterly reviews completed
e. Evidence that services were delivered in accordance with the support plan including the
type, scope, amount, duration, and frequency as specified in the Individual Support Plan
f.
Health inventories completed and nursing recommendations reflected in the Individual
Support Plan
4. Level of care evaluation is accurately completed
5. Evidence that individuals were provided choice of waiver services and service providers
6. Evidence that Service Monitoring is conducted and identified concerns submitted for entry into
Action Planning Tracking System
7. Evidence of implementation of Utilization Review process
8. Evidence that process is followed for individual moves, per Individual Moves & Portability of
Funds Policy - Directive 5.010
9. Evidence that the TCM Provider support coordinator reports and follows up on implementation
of provider action plan regarding abuse, neglect and death inquiries and investigations
10. Evidence of a system that ensures accuracy of information entered in the Division’s Individual
Information Management System
11. Evidence of 24/7 on-call system
12. Evidence that Quality Assurance processes and systems are in place
Local staff of the Division of Developmental Disabilities, acting in the capacity of “operational” agency
for all five waivers, provides oversight to the local TCM providers, reviewing a sample of case records to
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ensure all of the quality management functions have been carried out. All Individual service plans
developed by the local TCM entity are reviewed and approved by staff of the Missouri Division of
Developmental Disabilities. Similarly, individual service plans for new waiver participants who are being
enrolled in a waiver for the first time and any updated ISP for people already participating in a waiver
that includes increases in service budgets require approval by the Regional director or designee (state
staff).State staff ensures the entity acts in the best interest of the participant. To avoid potential
conflicts of interest, state staff is responsible for reviewing and approving all financial and functional
eligibility determinations. The state review of entities may include interaction/contact with a sample of
consumers and/or their guardians/family members to verify effectiveness of the procedures.
Entities providing both case management and services must document in the service plan that, as a
provider of service coordination and LTSS, the entity will ensure its employees will act in the best
interest of the participant and that no conflict of interest occurs. In addition, they must develop a
conflict of interest plan specific to the service delivery area and its circumstances. The plan must
include:
1. Information identifying potential conflict of interest situations;
2. Planned or ongoing initiatives intended to eliminate or mitigate the occurrence;
3. Actions intended to manage those ongoing situations that cannot be eliminated. These may
include, but are not limited to: an open door policy, non-retribution and whistle-blowers’
policies, rights committee review, and grievance policy.
4. Methods of communication required to inform the individual consumer and/or guardian, if
applicable, about the potential conflict.
The Missouri Medicaid Audit and Compliance Unit in the Department of Social Services (DSS) conduct
documentation reviews and investigate claims of Medicaid fraud or abuse. The DSS operates Cyber
Access, a web-based electronic health record program for Medicaid participants that allows healthcare
providers to e-prescribe, view diagnostic data, and review other Medicaid services provided which
ensures needs are being addressed.
Each waiver requires a statistically valid random sample of participant records be reviewed no less than
annually by the state Medicaid agency and the state operating agencies. A Raosoft Sample Size
Calculator is used to determine the sample size with a 95% confidence level, plus or minus 5%. Each
record is reviewed based on the most recent performance measures approved by CMS, with conflict of
interest examined closely throughout the review. The performance measures are based on CMS
assurances and sub-assurances. Performance measures address timely assessment and reassessments,
participant goals, participant choice, level of care determinations, service planning and service delivery,
and assuring the health welfare and safety of the participant.
All services plans are subject to review by state staff but approval of the service plan varies among
programs. Services plans for Personal Care, the Adult Day Care Waiver, the Aged & Disabled Waiver, and
the Independent Living waiver are created and approved by state staff in the DHSS. All services plans
under Private Duty Nursing and Medically Fragile Adult Waiver are developed by DHSS staff and subject
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to approval by staff in DHSS Central Office prior to implementation. AIDS Waiver service plans are
developed by contracted AIDS Waiver case managers and are reviewed and approved by DHSS staff
prior to authorization. Comprehensive Community Support plans of care are developed by state staff in
the DSS. The Home Health, Rehabilitation, Community Psychiatric Rehabilitation Services,
Comprehensive Substance Treatment and Rehabilitation, and Health Homes programs have plans of
care developed and/or reviewed by medical and other professionals that are subject to sampling
reviews by the Missouri Medicaid Audit and Compliance Unit within DSS and/or DMH but are not
subject to approval by state staff prior to implementation. All individual service plans developed by a
Targeted Case Management entity for the Comprehensive Waiver, Community Support Waiver, Missouri
Children with Developmental Disabilities Waiver, the Autism Waiver and the Partnership for Hope
Waiver are approved by the Regional director or designee (state staff) of the Missouri Division of
Developmental Disabilities.
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