Mentalhealthcarequandarylooms
Providers fear prior-authorization rule will be costly, delay treatment
When Carrie and Jeffrey Olsen took in their year-and-a-half-old foster child, Daemion, they knew that he would need a lifetime of guidance.
“He’s got a lot of emotional issues,” Carrie Olsen said of her now-9-year-old son. “There’s been lots of doctors, there’s been lots of tests, there’s been lots of trying to figure it out.”
Daemion has made advances after three years of therapy with a licensed clinical social worker paid for by Medicaid.
But now his mom fears that a change in the mostly federally funded, state-administered program threatens to undo that progress.
The state agency that administers Medicaid announced this summer that it would soon limit patients to three therapy sessions before requiring them to obtain pre-approval for continuing treatment.
Mental health advocates and care providers say the change will delay treatment and force some practitioners to stop taking Medicaid, leaving the most vulnerable with fewer options in a state already
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ranked last for overall mental health and access to care by Mental Health America.
Rationing care
When the change was announced, clinical social worker Pam Roberts realized she would have to ration Daemion’s care until his next batch of visits was approved, so she cut his appointments from twice to once a week.
In the first few days without his regular appointment, Daemion’s emotional issues caught up with him. He sneaked out the dog door while his mom slept in the other room, and he ended up in police custody.
“He’s like a cat with nine lives, and I’m just worried that it’s not going to be just a ride home and talk about, ‘Hey, that’s not a safe choice and something could happen,’” Olsen said through tears during a recent interview in her Las Vegas home.
Current policy allows Medicaid providers to offer up to 26 sessions — six months of therapy for a client who gets help once weekly — before obtaining approval for additional treatment.
But as of Aug. 15, Nevada’s mental health providers who take Medicaid for psychotherapy and neurotherapy services, including individual and group therapy and biofeedback, will need to obtain that approval before a client’s fourth session.
The change directly affects feefor-service Medicaid recipients — about a quarter of the 650,000 Nevadans insured through the program.
Managed-care groups, which cover the remaining 75 percent, can follow the state’s lead or set their own prior-authorization rules. Of the three organizations active in Nevada, Anthem Blue Cross Blue Shield and Silversummit Healthplan do not plan to change their policies, while Health Plan of Nevada declined to comment, according to state officials.
Preventing fraud
The change by the state’s Division of Health Care Financing and Policy was prompted by what the state says was a rise in fraud, including overbilling for services and false claims for services not provided.
An October 2017 audit that examined reimbursements for behavioral health outpatient services found the state had improperly paid up to $8.8 million in fiscal year 2016, for example.
But providers, especially those with small practices, say the rule change will inundate them with paperwork.
“It’s less expensive for me not to take Medicaid,” said Adrianna Wechsler Zimring, a Las Vegas psychologist and past president of the Nevada Psychological Association. “It’s just cheaper for me to (provide therapy) for free because of all the amount of time and energy and resources I have to have … to be able to keep up to date on the Medicaid requirements that are constantly changing.”
Psychologists and other mental health providers voiced their concerns about the proposed policy at a public workshop in late June. At the time, the new requirement, called a prior authorization, would have mandated that providers submit the paperwork after one session.
It was changed to three sessions after therapists said they wouldn’t have enough information on a patient after the initial visit to avoid the claim’s denial, said Medicaid administrator Marta Jensen.
“I think one of the misconceptions is this has been a reduction in services. It’s just not,” Jensen said. “It’s just putting the tools up front to ensure the medical necessity is there.”
She also said delays in receiving additional treatment should be minimal, with 99 percent of prior-authorization requests currently processed within five business days.
That may not be the case, however, when claims are denied and must be appealed, said Wechsler Zimring. In that event, she said, an extra hour or two of paperwork per client can easily swell to five extra hours.
And providers argue it has taken up to two or three weeks to resolve appeals in some cases.
“Medicaid can say, ‘Oh, it’s fine, it’s fine. Just have your therapist write a prior authorization,’ but it’s not that simple for the therapist,” said Roberts, Daemion’s social worker. “That requires them to have … an administrative staff, but a small private practice cannot afford an administrative staff.”
While the change will primarily affect children in Roberts’ and Wechsler Zimring’s practices, it will cut across all age groups.
Not ‘hashtag Vegas strong’
Route 91 Harvest festival shooting survivors still in therapy, for example, might have to stop seeing their therapist for a time if they’re covered by Medicaid and haven’t been approved through the state’s prior-authorization process.
“This does not seem very hashtag Vegas strong to me,” Wechsler Zimring said.
Cody Phinney, deputy administrator of the the Division for Health Care Financing and Policy, said the pre-authorizations will help the agency “protect the quality and quantity of services for the population we’re serving.”
State data showed that the $738,084 for neurotherapy services billed to Medicaid in the 2013 fiscal year had risen 2,345 percent — to more than $18 million — in the current fiscal year as of April.
“It’s not just about cost. I find it really personally hard when I see that we’re getting bills that are not attached to any services,” she said. “If there’s no (prior authorization) and there’s no hard stop in the system, those bills just pay and then we have to try to recoup from that provider.”
Chuck Duarte, the state’s former Medicaid administrator and now CEO of Community Health Alliance, agrees that fraud is a problem but said prior authorizations are a poor tool to try to use to combat it.
Now, he said, the burden will fall on providers who legitimately provide services and the patients, whose care is ultimately delayed and whose mental health is allowed to suffer.
“Imagine if in the medical world, you couldn’t do cancer screening and some work with the patient, and you said, ‘We’ll only treat you when you’ve got cancer,’” Duarte said. “That’s kind of how it feels.”
Contact Jessie Bekker at jbekker@ reviewjournal.com or 702-380-4563. Follow @jessiebekks on Twitter.