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Vitality Unlimited provides substance abuse treatment in Elko. (Jeff Scheid/The Nevada Independent)

Nevada Medicaid will decide next month whether to impose additional requirements for patients to undergo therapy on an ongoing basis, a move the state says will increase accountability and ensure people are getting the care they actually need but that mental health providers across the state are decrying as yet another barrier to access to mental health care for a vulnerable population.

The Division of Health Care Financing and Policy, which runs the state’s Medicaid program, will hold a hearing on Aug. 14 to decide whether to require psychologists, therapists and other mental health professionals to provide written documentation demonstrating medical necessity and receive prior approval to continue providing talk therapy or neurotherapy after three sessions with a patient. Mental health professionals are currently allowed to offer up to 26 sessions without prior authorization.

State officials describe the policy as an effort to be both fiscally and socially responsible, ensuring that providers are only getting paid for services that are actually necessary and that patients are receiving the right treatment for their condition. But opponents of the proposed policy change — including the Washoe Regional Behavioral Health Policy Board, the Nevada Psychological Association and the State Board of Marriage and Family Therapists and Clinical Professional Counselors, among others — argue that it will damage an already-thin safety net for patients by imposing additional administrative burdens on providers not keen on taking Medicaid in the first place and dissuade reluctant patients from continuing treatment.

The proposed policy change up for approval in August is a scaled back version of a proposal the division presented at a public workshop in June that would have required prior authorization before the first therapy session with a patient. (Talk therapy, also known as psychotherapy, is a broad term that refers to the kind of treatment a patient receives by talking issues out with a therapist; neurotherapy is a type of brainwave training that uses real-time displays of brain activity.)

The change will only apply to patients enrolled in Medicaid’s fee-for-service program, in which Nevada Medicaid reimburses individual providers for services rendered, and not those who are a part of Medicaid managed care, where the state pays an insurance company a flat fee to provide health services to a patient. Roughly one in four of the 650,000 Nevadans on Medicaid are enrolled in the fee-for-service-program.

The three Medicaid managed care organizations in Nevada are responsible for establishing their own prior authorization policies and have not communicated to the state any intent to change those policies, according to Nevada Medicaid. A spokeswoman for Anthem confirmed that no policy changes are currently on the table, while representatives for Health Plan of Nevada and SilverSummit did not respond to requests for comment on Monday.

The division’s original proposal received significant pushback from mental health providers, with roughly 80 to 100 people turning up to the June meeting in person and over the phone to express their concerns. In response, the state decided to instead put forward a proposal requiring prior authorizations after three sessions in order to allow the provider to establish a relationship with a patient before having to explain why he or she believes ongoing treatment is necessary.

Shannon Sprout, one of the division’s deputy administrators, said Medicaid routinely reviews its policies and looks for where updates might be needed. But she said the prior authorization proposal is also the byproduct of an executive audit report in October that identified inappropriate billing practices for behavioral health services within Medicaid.

Marta Jensen, who heads the state’s Medicaid division, said that the goal of the policy change isn’t to harm anyone, patients or providers alike.

“This was not a cold decision based on fiscal [analysis]. It really boils down to we care about the members they serve,” Jensen said. “We want them to get the services they’re eligible for. We’re asking for an additional step to make sure it’s medically necessary so we’re being good stewards of taxpayer dollars.”

But the state’s proposal doesn’t read that way to members of the mental health community who say they don’t understand why Nevada Medicaid would do something that could undermine the work the state has been doing to increase access to mental health care for low-income individuals.

Gov. Brian Sandoval has made mental health one of his focuses over his eight years as governor and was the first Republican governor to opt-into Medicaid expansion under the Affordable Care Act. That move allowed the state to decrease the number of behavioral health services it provides by relying more on community providers to treat low-income patients and get reimbursed through Medicaid. (A spokeswoman for Sandoval declined to comment on the proposed change.)

Robin Reedy, executive director of the National Alliance on Mental Illnesses Nevada chapter, said she believes the proposed change is “absolutely contrary” to that work.

“They’re balancing their budget on the backs of the people who are least likely to cause a fuss or fight it,” Reedy said. “In fact, they’re putting up a barrier for someone with a mental health condition because any slight barrier will stop them from moving forward and getting help. That’s the nature of the condition and what they’ve been trained to do.”

Concerns over prior authorization

During the 2017 session, the Legislature created four boards tasked broadly with examining mental health in the state and returning to lawmakers next year with their recommendations. One of those boards, the Washoe Regional Behavioral Health Policy Board, voted to oppose the policy change at its meeting last week.

In a letter, board chair Chuck Duarte appealed to Department of Health and Human Services Director Richard Whitley to intervene and withdraw the proposal from consideration, calling it a “barrier to care and an unreasonable administrative burden for providers.”

“Prior authorization requirements are not only administratively burdensome to providers, but specifically serve to reduce access to services and hence cut health care expenditures,” Duarte wrote in the July 16 letter. “This is particularly concerning as Nevada struggles with access to psychological services anyway.”

Nevada again landed in 51st place in the nation in Mental Health America's annual state rankings this year, and the state suffers from a chronic shortage of mental health professionals, with all 17 counties designated in full or in part as a mental health provider shortage area by the federal government. The overall barriers accessing mental health care in the state are felt most acutely by Medicaid patients, who typically have even fewer options of providers than patients with private health insurance do and often face additional difficulties accessing care due to life circumstances.

In interviews with The Nevada Independent, several mental health providers expressed concerns about the administrative burden of requesting prior authorizations for all Medicaid patients, a five-page form they estimate takes about an hour to complete per patient. They say it’s an extra step that will dissuade providers from wanting to take Medicaid patients due to the extra investment of time — and paid employee hours — the prior authorization requests will take.

“I can count as least six people who had told me if this thing goes through they’re leaving the network, individual providers in two agencies who have said, ‘We won’t be able to absorb the costs,’” said Jake Wiskerchen, the founder and clinical director of Zephyr Wellness.

In an interview, Duarte said that policy might not be the “straw that breaks the camel’s back” but that it may make providers question whether or not they want to continue caring for Medicaid patients.

“For providers in the community, it creates an administrative burden and for some of them, they may not want the hassle,” Duarte said. “They don’t get paid enough as it is and they probably don’t want to go through this administrative hassle.”

And even if they are able to handle the administrative burden of filling out the forms, providers say that prior authorization requests are often denied, either because they didn’t use the right language to describe someone’s medical condition or because they made a technical error, such as forgetting to submit supplementary documentation. They also say that although the state requires prior authorization requests to be processed within five business days, it often takes multiple weeks.

“The statement by division representatives that [requests] will be approved within five days is highly, highly inaccurate,” said Dr. Jordan Soper, secretary of the Nevada Psychological Association. “[Requests] people are submitting now are taking two weeks to get processed.”

Nevada Medicaid has questions about that assertion, though. Sprout said that data the state has received from their vendors shows 99 percent compliance with the five-day processing time frame but that the state wants to know if that number isn’t accurate. Jensen said that the state has asked providers for specific information about specific cases in which a prior authorization took longer than five days but hasn’t received any further details.

“This is where the difficulty or frustration hits is we hear about the concerns at the public hearing and ask for additional information,” Jensen said. “They never follow through and give us the data to help them.”

Sprout also said that the state plans to monitor the implementation process and see if Medicaid is seeing an abundance of denials. If so, she suggested that the state could hold a webinar to offer additional provider training to help providers properly fill out the prior authorization form and avoid any unnecessary denials. And, at the end of the day, she said the state can always change its policy if it’s not working.

Sprout also stressed that the change is not a cut in services. Sprout said that if patients need 26 sessions, they still can receive 26 sessions — or even more, if that’s what’s deemed medically necessary.

“This is a vulnerable population and to put that prior authorization, it’s ensuring that this is the right service for them based off of what the treatment indicates that’s submitted with the prior authorization,” Sprout said. “We want to make sure recipients are getting the right service and demonstrate that this is medically necessary.”

But providers say that experience leads them to believe that the overall impact of prior authorization requests will be exactly that — a cut in services.

“I don’t have confidence that these psychotherapy services are going to get authorized,” Wiskerchen said. “These people are going to get three sessions and then have the rug pulled out from under them.”

Duarte, who was in Jensen’s role at Nevada Medicaid until 2012, said that the inherent purpose of prior authorizations is to create a barrier in order to reduce utilization of a particular service, calling them a “blunt instrument to cut costs.”

He said that the state often makes decisions in the short term to address its budget in the current fiscal year to avoid having to go to the Legislature’s Interim Finance Committee and have debt forwarded to the next fiscal year or the next biennium. But he said that the state could be more upfront with providers why the change is needed and why they think in the long run it won’t be harmful.

“I know they may have financial issues and budget problems, but this is no way to run a railroad, especially in one of the states that has one of the worst records in mental health,” Duarte said.

Medicaid reimbursement clawbacks

On top of the proposed policy change, mental health professionals say they’re reeling from an effort by Nevada Medicaid to recoup reimbursements for behavioral health services that were erroneously paid out between 2016 and 2018.

For instance, the state recently determined that providers had been getting reimbursed for psychotherapy services in excess of the current 26 session limit for patients who have not received prior authorization for more sessions. Jensen said that there is a list of criteria in the Medicaid system that have to be met when a claim is submitted in order for it to be processed, and the requirement for a prior authorization after 26 visits was missing from that list, causing claims to be erroneously processed.

The state is now in the process of clawing back reimbursements to providers that were paid out in error over a two-year period. Providers acknowledge that the payments were erroneously made but argue that it’s the state’s fault for not notifying them immediately about the problem.

David Briggs, who runs True North Treatment Center in Reno, estimates that he owes about $12,000 over the two year period.

“For me it will be painful, but I won’t go out of business,” Briggs said. “I was so small in 2016. Now, I’ve got like nine therapists who work here. If I had nine therapists in 2016, I would not be able to recover.”

The psychologists, too, are facing their own recoupment efforts because of a change in Medicaid provider type codes. As a result of the change, the reimbursement psychologists receive for certain services went down substantially but they kept getting paid at the higher rate.

Soper, the secretary of the Nevada Psychological Association, said that some businesses have already closed as a result of the recoupment efforts. More, she said, will be canceling their contracts with Nevada Medicaid because of it.

Jensen said that the state does not want to see businesses close their doors or stop taking Medicaid patients and that the division will “absolutely” work with businesses to make the payments in a way that works for them.

“I have no interest in closing down, I need providers,” Jensen said. “They can request to negotiate. Absolutely.”

What’s next

The division plans to hold a hearing on August 14 during which it can adopt the proposed prior authorization policy change. Jensen said that providers will be welcome to make further comment at that hearing, but that unless there’s something compelling that hasn’t been raised before, the division will likely move ahead with adopting the policy.

“We do have an option to pull it,” Jensen said. “But we typically move forward, and it becomes effective the next day.”

But until the hearing, providers plan to keep organizing and speaking out against the proposal in an effort to stop it. One group, United Providers of Mental Health, is planning on holding a town hall on Wednesday to discuss the proposed change, and a licensed clinical social worker recently started a website called NVProviders in an attempt to unify mental health providers in opposition to both the prior authorization policy and the recoupment efforts.

“This effort to bring the provider community together is aimed squarely at increasing the voice, representation and power of providers against the actions of Nevada Medicaid that threaten our literal financial survival,” Kristopher Komarek, a licensed clinical social worker in Carson City, wrote on the website. “We need to improve the relationship between providers and Nevada Medicaid, and to ensure that the communities and clients we serve receive the services they need and deserve.”

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