Nevada Medicaid approved a requirement that therapists receive prior approval before providing more than five therapy sessions to a patient at a meeting on Tuesday after nearly two hours of public comment from therapists, patients and mental health advocates expressing their concerns about the proposed change.

The new policy, which takes effect on Oct. 1, will require psychologists, therapists and other mental health providers to submit written documentation to the state’s third-party vendor demonstrating the medical necessity of treatment and receive prior approval to continue providing both talk therapy and neurotherapy services after five sessions with a patient. The final policy is a scaled back version of earlier proposals from Medicaid to require prior authorization before the first session or after three sessions, both which received significant pushback from the mental health community over the last few weeks.

The policy 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 covered under Medicaid managed care, where the state pays an insurance company a flat fee to provide health services to a patient. About one in four of the 650,000 Nevadans on Medicaid are enrolled in the fee-for-service-program.

Over the past few weeks, state officials have described imposing some sort of prior authorization requirement in an effort to be fiscally responsible, particularly in the wake of an executive audit in January that identified inappropriate billing practices for behavioral health-care services within Medicaid. That audit found that 15 percent of client files lacked documentation for services rendered, 5 percent of others had documentation but did not contain the right Medicaid code for the services rendered, and another 6 percent of those with documentation showed that non-reimbursable services were billed and paid as case management services.

But those in the mental health community have argued that implementing any form of prior authorization would result in reduced access to services for the state’s most vulnerable, many whom already face significant barriers accessing treatment.

Medicaid administrator Marta Jensen said at the meeting that the decision to allow five therapy sessions and delay the implementation of the policy for six weeks came as a result of meetings with mental health providers over the last few weeks. But she also continued to emphasize the need to take some sort of action to curb potential abuse within the Medicaid system.

“They were very honest with their concerns on the table, and we discussed our concerns of how do we combat the fraud and abuse that’s in this industry at the moment,” Jensen said.

The initial prior authorization proposal, which was presented at a June workshop, had recommended that providers receive approval before the first therapy session with a patient, which received sharp criticism from the mental health community. Medicaid then proposed requiring prior authorizations after the third therapy session instead, a policy that was then amended to the five session policy on Tuesday.

Medicaid also made the decision to delay the policy’s implementation from Wednesday, the day after the meeting, to October 1 in order to give providers, patients, mental health advocates and the state time to come together in a working group to consider alternate solutions. Jensen said that if the working group can come up with a better proposal, Medicaid could retract the five-session prior authorization policy and move forward with the new idea before October.

Jensen thanked the providers who reached out to her for having a “professional, meaningful discussion.”

“I’ve learned a lot and I think there’s some work that needs to be done and we’re certainly willing to move forward,” Jensen said.

Some therapists expressed gratitude to Jensen and the Medicaid division at the meeting for their willingness to work with them on the proposal. But many in the mental health community continued to express concerns that the policy will still disrupt the continuity of care for patients on Medicaid if the working group isn’t able to come up with a better solution in time.

“Five sessions. That’s only about two and a half weeks of care. The concern is what happens after those first five sessions. How soon can we get the care that those kids need?” said Dan Musgrove, who chairs the Clark County Children’s Mental Health Consortium.

Robin Reedy, executive director of the National Alliance on Mental Illnesses Nevada chapter, echoed the sentiment.

“We appreciate you listening, but five doesn’t do it,” Reedy said at the meeting.

Patients echoed those concerns, both in testimony at the hearing and in interviews with The Nevada Independent. Many of them worried about what would happen if they were denied the ability to continue the ongoing treatment they have been receiving.

Scott Denman, 34, told the Independent that therapy has helped him “so much” with his depression and anxiety.

“It got me grounded,” Denman said. “I found a peace within myself.”

But Denman is still homeless and spent the night before the hearing sleeping in a park. He started to tear up when talking about what could happen if he was unable to continue therapy.

“They’ve had my back, helped me,” Denman said. “They’re cutting back the wrong stuff.”

Karen Perry, 56, started going to therapy four years ago for a cocaine addiction and depression after she suffered a stroke. She said that therapy has finally gotten her to the point where she can “resist” her addiction on her own.

“I don’t have another option,” Perry said. “They can’t cut my services.”

One mother testified at the hearing about how therapy has helped her three children, who were previously in foster care. But she said that she doesn’t feel like Medicaid has her back.

“We have beautiful loving creative children who could be anything they want to be,” said the mom, Jill Craig. “But we walk a very fragile line where at any moment we may need to call our therapist to talk our child down from the ledge so to speak.”

The proposed changes have also sowed seeds of mistrust both within the provider and patient communities. Several people who testified at the meeting via a teleconference line declined to give their names for fear of retribution, with some suggesting that Medicaid was targeting providers with audits for speaking up.

Jensen said at the meeting that she was unaware of any audits that were issued as a result of someone asking for their denials to be reviewed and asked providers to come forward to him personally, if they feel comfortable, to address any concerns.

“I would like to look into this because we are not to be targeting anybody just because they’re trying to get paid,” Jensen said.

Touching some of those concerns, Jake Wiskerchen, the president of the Nevada Board of Examiners for Marriage and Family Therapists, thanked Medicaid for granting the licensing board some flexibility when it faced what he described as “internal collapse” last year.

“This audience needs to know you are not sinister beings and you don’t have horns growing out of your head. You saved Nevada’s mental health-care workforce by doing that and my appreciation for that needs to be expressed,” Wiskerchen said.

But, as the founder and clinical director of Zephyr Wellness, Wiskerchen continued to express serious concerns about the prior approval process.

“I find that the very prospect of having my master’s degree and nearly 10,000 hours of clinical care, education and training called into question by someone remotely on a piece of paper — if I determine through the powers afforded to me through my statutorily defined license that a given client should receive services, I would expect that any insurance company that credentialed me to trust my clinical acumen and not override it,” Wiskerchen said.

However, he said that he was “very pleased” with Medicaid’s decision to delay implementation and said that he looks forward to collaborating with the state over the next few weeks.

“I want solutions that will benefit all of Nevada’s constituents, which absolutely includes fiscal responsibility,” Wiskerchen said. “When we save money, everybody benefits.”

Updated 8-15-18 at 11:01 a.m. to correct a quote by Jake Wiskerchen.