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Glossary

Conflict-free case management

The federal requirement, in 42 CFR 441.301(c)(1)(vi), that the entity providing a Medicaid waiver member's case management or writing their service plan may not also provide their waiver services, or have an interest in a provider that does, unless the state shows no other willing and qualified entity exists.

Also conflict-free care management, CFCM, conflict of interest rule

The rule came in with CMS’s 2014 home and community-based services regulation. The person-centered service plan, the document that says what a waiver member will receive and from whom, must be developed by someone with no financial interest in the answer. 42 CFR 441.301(c)(1)(vi) says that providers of waiver services for the individual, and anyone who has an interest in or is employed by such a provider, “must not provide case management or develop the person-centered service plan”, with one exception: a state may allow it where it shows that the conflicted entity is the only willing and qualified one in the area, and then only with firewalls and a clear way for the member to object.

States have spent the decade since reorganizing around it. Colorado moved every region to a single case management agency separate from its providers; Indiana, Louisiana and Georgia route case management through entities that deliver nothing else; the state webinars and attestations that rank for the phrase are the paper trail of that work.

For the Medicaid waiver case management agency the rule has a consequence that is easy to miss. The agency that assembles the application and writes the plan is, by law, not the agency treating the member. It holds no chart of its own. Every clinical fact it needs, for the level-of-care form and for the plan, is in the records of providers it does not control and may never have dealt with, and the authority to obtain them comes from the member rather than from a treating relationship. That is the shape of the records problem in this segment, and it is different from a home health agency’s or a PACE organization’s, which are themselves providers. It is why the case management page on this site describes the records moving on the applicant’s release, and why a tool built for treating providers is not automatically a tool for this work.

Where it is defined

Vivlio for case managementThe physician's documentation behind the level-of-care form, retrieved before the state's clock runs out.

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  • Coverage comes firstVivlio retrieves from providers, hospitals and health systems it can reach through national exchange networks and direct connections. Name the facilities your patients come from on the form and we check coverage before anyone spends thirty minutes on a demo.
  • You can say what the chasing costsThe form asks how many hours a week your team loses to chasing records. If nobody can put a number near it, the case for Vivlio is not there yet, and we would rather say so than sell you a demo.
  • Patients and files at volumeThis is built for intake that runs every day. For one record, once, your patient can request it from the provider directly, and that will be faster than going through us.
  • Treatment, with the paperwork doneProduction access needs an NPI, a declared purpose of use and a signed BAA. Nobody swipes a card onto live PHI.

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