Missouri: Ownership and Oversight
Restricted: the most mechanics-heavy collaboration state in the country. Missouri stacks more concrete requirements onto APRN collaboration than any state in this series: a month of continuous on-site practice, a 75-mile radius, chart-review percentages on a 14-day clock, a combined 6 FTE cap, and posted patient disclosures. It also invented its own provider category — the assistant physician.
Who the statute actually covers
- "Collaborative practice arrangement" (CPA) (RSMo § 334.104; 20 CSR 2200-4.200 / 2150-5.100): the written agreement, protocols, or standing orders delegating medical acts and prescribing to an APRN; reviewed annually with documentation retained.
- Geography and presence: before practicing where the collaborating physician is not continuously present, the APRN completes one month of practice with the physician continuously present; thereafter the physician (or designee) practices within 75 miles by road, waivable where the arrangement outlines telehealth, with rural-health-clinic and Board-application waivers; the physician must be immediately available for consultation at all times.
- Chart review on a clock: the collaborating physician (or designee) reviews charts every 14 days, including a minimum of 20% of charts in which the APRN prescribes controlled substances; verify current general-review percentages against the joint rules.
- The combined cap: a collaborating physician may not have CPAs with more than 6 full-time-equivalent APRNs, PAs, and assistant physicians combined (hospital inpatient, public health, and CRNA-supervision exceptions).
- "Assistant physician" (RSMo §§ 334.036–334.037): Missouri's unique category — medical school graduates who have not completed residency, practicing primary care in underserved areas under collaborative arrangements with their own on-site month, 10% chart-review floor, and controlled-substance limits.
1. Who can own what
| Entity / Path | Who may own | Key limits |
|---|---|---|
| Medical professional entities | Licensee-owned professional corporations (RSMo ch. 356); corporate practice policed through licensing law. | |
| APRN-owned practice | Possible but heavily tethered: the owner still needs the on-site month, the 75-mile physician, the 14-day reviews, and a CPA slot within some physician's 6 FTE cap. | Losing the collaborator stops the practice cold; there is no Missouri grace period. Build backup-physician designations into every CPA. |
| PA path | Written collaborative/supervision arrangements under the PA act, counted within the same combined 6 FTE cap; controlled-substance delegation with Schedule II-hydrocodone/III limits. | Verify current PA-specific mechanics (20 CSR 2150-7) when drafting. |
| Lay / MSO | Standard exclusion from the professional entity; MSO at FMV. |
2. Collaborative and supervisory oversight
| Role | Agreement required | Oversight mechanics | Path to independence |
|---|---|---|---|
| PA | Written collaborative arrangement with a Missouri physician; counted in the combined 6 FTE cap; CS delegation per rule with a five-day supply limit on Schedule II-hydrocodone and Schedule III narcotics (buprenorphine MAT exception). | On-site and review mechanics parallel the APRN framework; confirm current percentages in 20 CSR 2150-7 before drafting. | None. Missouri has no PA independence pathway. |
| NP / APRN | Written CPA (§ 334.104) delegating treatment and prescribing; one-month continuous on-site start; 75-mile proximity (telehealth waiver in the arrangement); physician immediately available; annual documented review; office disclosure statement posted. | Chart review every 14 days including 20% of controlled-substance charts; combined 6 FTE cap; prescriptive authority requires 1,000 documented APRN practice hours before the CS certificate; Schedule II limited to hydrocodone products, and Schedule II-hydrocodone/Schedule III narcotics capped at a 5-day supply (30-day buprenorphine MAT exception); hospice Schedule II expansions per recent legislation. | None. Missouri is a restricted state with no hours-based exit; FPA bills fail annually. |
3. Primary authorities
- RSMo § 334.104; 20 CSR 2200-4.200; 20 CSR 2150-5.100.
- RSMo § 335.019 (1,000-hour prescriptive authority prerequisite); § 195.017 framework.
- RSMo §§ 334.036–334.037; 20 CSR 2150-2.240.
- RSMo § 334.735 et seq.; 20 CSR 2150-7.
Practical read: Missouri is where multi-state telehealth templates go to die: the on-site month, the 75-mile rule, and the 14-day/20% controlled-substance review cannot be papered over, and the telehealth proximity waiver only works if the arrangement actually says so. Price Missouri collaborations accordingly, audit the physician's total FTE count across every arrangement they hold, and never let a Missouri APRN practice ride on a single collaborator with no designated backup.
General education, not legal advice.