Policy for Conflict-Free Case Management
CMS rules only allow organizations to provide both direct services and case management to the same person when KDADS approves the organization as an Only Willing and Qualified Provider (OWQP). This page will explain the policy for OWQP Approvals. It includes the requirements for approval and participant’s rights.
Overview of the Policy
The Centers for Medicare & Medicaid Services (CMS) does not allow one organization to provide both direct services and case management to the same participant in most cases.
There are three ways for a provider to follow CMS rules on conflicts-of-interest:
They only offer case management or direct waiver services, never both.
They offer case management and direct waiver services, but never to the same person.
They offer both case management and direct services to the same person, and KDADS has given them Only Willing and Qualified Providers (OWQP) Approval.
The goal of this requirement is to address conflicts of interest. Conflicts of interest are when what is best for a company and what is best for a participant may not line up.
KDADS will only approve providers as OWQPs for a service (option 3 above) if every other provider in the county is unwilling or unqualified to provide either TCM or the direct service. Providers with OWQP approvals for a service also have to implement protections to reduce the impact of conflicts of interest on participants.
A provider is unwilling or unqualified if any of the following are true:
They do not provide case management or the specific direct waiver service.
They do not serve the specific county.
They cannot serve more participants.
They cannot meet the participant’s support needs (or are not in the participant’s MCO network).
What Is in the OWQP Approval Policy?
The policy for OWQP Approvals explains:
When service providers can and cannot deliver conflicted services
The safeguards that protect participants
The rights participants have when receiving conflicted services.
Sometimes one provider organization and another organization that seems separate are still linked together financially. These groups of providers also cannot provide direct waiver services and case management to the same person unless they have written approval from KDADS.
Review the Complete Draft of the
Conflict-Free Cases Management Policy
Rules for OWQPs
When KDADS gives a provider an OWQP Approval, the provider needs to follow certain rules to keep it and help protect participants. You can see the list of rules below.
KDADS can penalize any providers that break these rules, including making them stop offering targeted case management, and/or having them submit a corrective action plan. An OWQP Approval is only good for one year. After that, a provider must apply to renew it.
The OWQP Policy is not designed to be permanent. It is a way to give providers and CDDOs enough time to increase capacity. The long-term goal is for all participants to receive non-conflicted services.
Keeping Case Management and Direct Services Separate
OWQP Providers must take certain steps (called “administrative separations”) to keep their case management work separate from their direct service work. These separations include:
Hiring different people for case management and direct services
Using different managers to supervise case management and direct service staff
Making sure case management and direct service staff work in different physical areas
Storing physical files for case management and direct services in different areas
Installing firewalls to keep electronic files, data, or information separate
Explaining Conflicted Services to Participants
Before a provider can deliver conflicted services, the CDDO must explain conflicted services to participants and get their consent. All participants must sign a consent form and give their informed consent. The policy details how the CDDO will share this information with MCOs and KDADS.
Moving Participants to Nonconflicted Providers
If a new, nonconflicted provider becomes available, CDDOs must:
Let participants getting services from an OWQP know a nonconflicted provider is available
Help the participant transition to a nonconflicted provider (if the provider is available during the participants annual plan renewal)
Handling Complaints
When a participant complains about their OWQP, their case manager must share that complaint with the participant’s MCO and CDDO. Afterwards, the MCO must make sure that the participant’s concerns are resolved appropriately.
Participants can also file a dispute with KDADS if they think KDADS was wrong to give a provider an OWQP Approval.
Monitoring and Oversight
KDADS and CDDOs will work together to make sure that providers follow the rules in the policy.
KDADS will check claims data to make sure every organization that provides conflicted services has an OWQP Approval. KDADS will also check that OWQP providers have the right separations in place.
MCO Care Coordinators and Case Management
If a conflicted provider does not follow the policy, they will lose their OWQP Approval. In that case, the participant’s MCO Care Coordinator will temporarily take over case management.
Applying for OWQP Approval
CDDOs apply for OWQP Approvals on behalf of providers. Applications can be for an agency to be the OWQP for a specific participant or within an entire county for specific service(s).
Before submitting an application, CDDOs will check to see if there are any other willing and qualified providers in an area, and if the provider has the right separations in place.
They will also collect consent forms before an organization starts providing conflicted services.
KDADS will review complete applications within 10 business days and let CDDOs and MCOs know about their decision.
