Follow the Money: Campaign finance reports show GOP edges in key Assembly races, tight contests in State Senate

Front of the Nevada Legislature building at night

A year after legislative Republicans became close to an endangered species after widespread 2018 electoral defeats, the party’s attempted comeback was boosted by candidates in several key races outraising incumbent Democratic lawmakers during the last year.

Details from the 2019 contribution and expenses reports, due on Jan. 15, detailed how much legislative incumbents and candidates raised over the last calendar year and painted a more hopeful picture for Republicans in several “swing” Assembly races, with a more mixed view in competitive state Senate seats.

Although there are 63 seats in the Legislature — 42 Assembly members and 21 senators — actual control of the body, or more likely whether or not Democrats have a two-thirds majority (required for passing any increase in taxes) in either body, will likely come down to just a handful of competitive seats up in 2020. 

Changing the balance of the state Assembly, where Democrats enjoy a 29-13 seat advantage, could be the best ticket for Assembly Republicans. In at least three races — Assembly Districts 4, 29 and 37 — Republican candidates reported raising at least six figures and each substantially outraised the Democratic incumbent in the seat.

Only 10 seats are up for election in the Senate, with members serving staggered four-year terms. Democrats control 13 seats — one shy of a super-majority — but have not endorsed candidates in the two most likely pick-up districts; Heidi Gansert in Senate District 15 and Scott Hammond in Senate District 18. And those incumbents will start with a significant financial advantage — Gansert raised $245,000 in 2019, and Hammond also pulled in $107,800.

Senate Democrats will also have to work to defend two competitive seats — Senate Majority Leader Nicole Cannizzaro’s Senate District 6 and the open Senate District 5, vacated by termed-out Sen Joyce Woodhouse. They’ll also have to deal with a competitive, three-way primary in safely Democratic Senate District 7 between caucus-backed Roberta Lange and two long-time Assembly members, Richard Carrillo and Ellen Spiegel.

And with no major statewide or federal races (beyond congressional seats and the presidential election) on the ballot, it’s likely that more attention and funds will make their way to down-ticket legislative races, especially ahead of an expected redistricting after the 2020 Census that could determine the political trajectory of the state over the next decade.

Fundraising reports, especially those filed nearly a year before an election, aren’t a perfect barometer of the success of any particular candidate, but offer a helpful context in determining which races that individual parties determine to be the most winnable and whether or not individual candidates have the resources to compete in a down-ballot race. (It’s also worth noting that incumbents are disadvantaged in fundraising because of a legally required “blackout” period before, during and shortly after the 120-day legislative session).

On the flip-side, a close examination of major contributors can pull back the veil on which businesses or industries are trying to curry favor with lawmakers ahead of the 2021 legislative session. 

Here’s a look at the financial status of major legislative races:

Major state Senate races

Although 10 state Senate races will be on the 2020 ballot, only a handful of races are likely to be competitive and shift the current 13-8 seat advantage currently held by Democrats.

A key battleground will be in Senate District 6, which is held by Cannizzaro, who narrowly beat former Assemblywoman Victoria Seaman in the 2016 election. Senate Republicans have endorsed April Becker, a Las Vegas-based attorney. Democrats make up 40 percent of registered voters in the district, and Republicans make up roughly 32.8 percent of registered voters.

Cannizzaro, who also beat back a politically motivated recall attempt in 2017, starts the race with a significant financial advantage after raising more than $326,000 throughout 2019, spending just $22,000 and ending the reporting period with $531,000 in the bank. Her top donors include $30,000 from properties affiliated with the Las Vegas Sands and $10,000 checks each from the Mirage, Switch and the Home Building Industry PAC, as well as nearly $10,000 from Woodhouse’s campaign.

But Becker’s first campaign finance report isn’t shabby; she reported raising nearly $313,000 over the fundraising period (including a “written commitment” from herself for $125,000) and ended the period with $152,000 in her campaign account.

Top donors to Becker included several Republican senators ($10,000 each from James Settelmeyer and the Senate Republican Leadership Conference, $5,000 each from Ben Kieckhefer, Joe Hardy and former state Sen. Michael Roberson and $2,000 from Keith Pickard), as well as $10,000 each from Abbey Dental Center owner Sanjeeta Khurana, the law firm of Gerald Gillock & Associates and Nevsur, Inc. (owned by Bruce and Barry Becker ).

Another highly competitive seat is Senate District 5, where Woodhouse narrowly beat Republican candidate and charter school principal Carrie Buck by less than one percentage point in the 2016 election. Democrats make up 38.4 percent of registered voters in the district compared to 32.6 percent for registered Republicans.

Buck, who is running again and has been endorsed by Senate Republicans, reported raising nearly $63,000 and ended the fundraising period with nearly $58,000 in the bank. Her top donors were fellow Republican senators; $10,000 each from the caucus itself and Settelmeyer, $5,000 each from Kieckhefer, Roberson and Hardy and $2,000 from Pickard.

But Buck’s fundraising total was eclipsed by Democrat Kristee Watson, a literacy nonprofit program facilitator endorsed by Senate Democrats in October.

Watson, who ran unsuccessfully for a Henderson-area Assembly seat in 2018, reported raising nearly $87,000 through the fundraising period, with a significant chunk coming from transfers from other candidates and office-holders. She received $10,000 contributions each from a PAC affiliated with Cannizzaro and the campaigns of Sens. Woodhouse, Chris Brooks, Marilyn Dondero Loop, and $5,000 from the campaigns of Sens. Melanie Scheible, Julia Ratti and Yvanna Cancela.

Other potentially competitive state Senate races feature a lopsided fundraising advantage for the incumbent. Democratic Sen. Dallas Harris in Senate District 11 was appointed to fill the term of now-Attorney General Aaron Ford, and reported raising nearly $46,000 over the fundraising period ($65,000 cash on hand). Her Republican opponents, Edgar Miron Galindo and Joshua Dowden, raised only $7,250 and $ 11,500 respectively over the fundraising period.

Two Republican incumbents up for re-election also posted impressive fundraising numbers that far outstripped potential opponents. Gansert in Senate District 15 raised nearly $246,000 and has nearly $237,000 in cash on hand; potential Democratic opponent Lindsy Judd did not file a 2019 campaign finance report.

In Senate District 18, incumbent Hammond raised nearly $108,000 and has more than $91,000 left in his campaign account; potential Democratic opponent Liz Becker raised $21,700 in comparison and has just $11,200 in cash on hand.

Primary battles

One of the most intriguing legislative races could come in the three-way Democratic primary to replace longtime Sen. David Parks, who is termed out of his Senate District 7 seat. Two Assembly members — Ellen Spiegel and Richard Carrillo — are running for the seat, but state Senate Democrats have thrown their weight behind another candidate, former state party head Roberta Lange.

Lange — who only made her bid for the seat official in mid-December — reported raising more than $64,000 for the seat, essentially during only the last two weeks of December. Her major donors included $10,000 from Cannizzaro’s political action committee, and $5,000 each from six incumbent senators — Ratti, Brooks, Scheible, Woodhouse, Cancela and Dondero Loop. She also received $2,500 from Parks, $1,000 from former U.S. Sen. Harry Reid’s Searchlight Leadership PAC and $5,000 each from UNLV professor and former gaming executive Tom Gallagher and his wife, Mary Kay Gallagher.

But she faces a potentially tough primary fight from Spiegel, who raised $63,000 throughout 2019 and has nearly $213,000 in available cash on hand. Her top contributor was Cox Communications ($10,000 cumulative) but other top givers included the Nevada REALTORS PAC, pharmaceutical company trade group PhRMA, health insurance giant Centene and AT&T ($3,000 from each). 

Carrillo lagged behind both Lange and Spiegel in initial fundraising reports. He reported raising $29,500 throughout the fundraising period, spending $37,600 and having just $17,000 left in available cash. His biggest contributor was the Laborers Union Local 872, which donated $12,500 through contributions by five affiliated political action committees. Other top contributors include tobacco company Altria and the political arm of the Teamsters Union ($5,000 each), and $3,000 each from Nevada REALTORS PAC and the Nevada Trucking Association.

Another major primary election is brewing between Republican candidates Andy Matthews (a former campaign spokesman for former Attorney General Adam Laxalt) and Michelle Mortensen (former television host and congressional candidate) in a primary for the right to challenge Assemblywoman Shea Backus in Assembly District 37.

Matthews raised a massive $154,000 over the fundraising period, the highest amount of any Republican Assembly candidate and the second most of any Assembly candidate behind only Speaker Jason Frierson.

He reported spending $23,800 and ending the period with more than $130,000 in available cash. His top donors included $10,000 combined from manufacturer EE Technologies and founder Sonny Newman, and $5,000 each from Las Vegas-based businesses Vegas Heavy Haul and InCorp Services, Inc. 

Mortensen also posted a substantial fundraising total; more than $102,000 raised, $9,500 spent and more than $93,000 in cash on hand. Her major donors included primarily family members; her husband Robert Marshall and his company Marshall & Associates ($20,000 total), her father-in-law James Marshall ($10,000) and maximum $10,000 donations from several family members including Betty Mortensen, Tom Mortensen, Ryan Mortensen and Mila Mortensen.

Both Republican candidates outraised incumbent Backus, who raised nearly $25,000 during the reporting period and has nearly $64,000 left in cash on hand. Her top donor was Wynn Resorts, which gave her $5,000. Backus narrowly defeated then-Republican Assemblyman Jim Marchant in the 2018 election, the first time a Democrat won the district in four election cycles.

Another competitive primary is happening in Assembly District 36, where appointed Assembly Republican Gregory Hafen II is facing off against Joseph Bradley, who ran for the seat last cycle against former Assemblyman James Oscarson and famed brothel owner Dennis Hof, who won the primary but died before the election.

Hafen reported raising $62,000 over the fundraising period (including a $9,500 loan) and has nearly $47,000 in cash on hand. Bradley reported raising $54,000 and has $38,500 left in his campaign account.

Key Assembly races

Nevada’s Assembly Democrats hit a potential high-water mark in 2018, winning control of 29 seats for the first time since 1992 and gaining enough seats to relegate Assembly Republicans to a super-minority (fewer than two-thirds of members).

But in a handful of competitive Assembly seats currently held by Democrats, Republican candidates posted substantial fundraising totals that not only eclipsed but often lapped the amount raised by incumbent Democrats, giving Republicans a financial leg up in some of the state’s most competitive legislative districts.

In Assembly District 4, first-term lawmaker Connie Munk reported raising $18,600 throughout 2019 and ended the period with just over $30,000 in cash on hand. Her biggest donors were PhRMA and trial attorneys-affiliated Citizens for Justice, Trust.

But her fundraising total was overwhelmed by Republican candidate Donnie Gibson, who reported raising $115,000 and has $87,000 left in his campaign account. Gibson, who runs a grading and paving company called Civil Werx, received maximum contributions from home builders and developers: $10,000 each from Associated Builders & Contractors, Associated General Contractors, the Nevada Contractors Association and the Home Industry Building PAC.

A similar disparity in fundraising totals was also present in Assembly District 29, where incumbent Democrat Lesley Cohen reported raising $16,000 over the fundraising period and has just under $50,000 in available cash.

Steven Delisle, a dentist and former state Senate candidate who announced his intention to run for the Assembly seat on Thursday, reported raising more than $134,000 for the race against Cohen, including a $125,000 loan to his campaign account.

But Democrats may have caught a break in Assembly District 31, where incumbent Skip Daly has won multiple races despite representing a district that went for President Donald Trump in 2016. Daly raised $46,425 through 2019 and has $75,800 left in his campaign account.

Assembly Republicans initially rallied behind Jake Wiskerchen, a marriage and family therapist who reported raising $27,700 for the race and had $19,000 in cash on hand at the end of 2019. But Wiskerchen opted to publicly drop out of the race in early January, leaving Republicans without an endorsed candidate for the time being. Daly’s 2018, 2016 and 2014 opponent, Jill Dickman, reported raising $8,800 in 2019 and has nearly $104,000 in leftover campaign cash.

Legislative leaders

Democratic Assembly Speaker Frierson reported raising more than $233,000 through the fundraising period, spending $174,000 and ended the period with just under $475,000 in cash on hand. His top contributors included a wide swath of Nevada businesses, including $10,000 each from Southern Glazer’s Wine and Spirits, the campaign account of former Assemblyman Elliot Anderson, Home Building Industry PAC, MGM Resorts and UFC parent company Zuffa, LLC. He also received $5,000 from the Vegas Golden Knights.

Republican Assembly Leader Robin Titus, who took over the caucus leadership position after the 2019 legislature, raised just over $38,000 during the fundraising period, spending more than $16,000 and ending the period with $72,000 in cash on hand. Top contributors to Titus included PhRMA and the Nevada REALTOR PAC ($5,000 each).

Her Republican counterpart in the state Senate, Settelmeyer, reported raising nearly $95,000 over the reporting period, with top contributors including UFC parent company Zuffa ($7,500), TitleMax, Nevada Credit Union League PAC, Grand Sierra Resort and Storey County businessman Lance Gilman ($5,000 from each). Settelmeyer ended the reporting period with $137,000 in cash on hand.


Although he isn’t up for re-election until 2022, Gov. Steve Sisolak broke fundraising records for Nevada governors in their first year in office after raising more than $1.6 million for his campaign and another $1.7 million for two closely affiliated political action committees. 

Sisolak reported having more than $2.3 million in available cash on hand at the end of 2019, and only reported spending $164,000 throughout the year. The governor also raised $1.7 million between the Sisolak Inaugural Committee and the Home Means Nevada PAC, which were initially set up to manage Sisolak’s inaugural events but have since been used for pro-Sisolak advertising. Political action committees in Nevada are allowed to accept unlimited donations.

Updated at 12:55 p.m. on Saturday, January 18th to include fundraising totals from Senate Republican candidate Joshua Dowden.

Nevada Medicaid to rescind prior authorization policy changes after provider concerns

Update 9/27/18 at 2:20 p.m.: Nevada Medicaid is officially stepping back from plans to limit the number of psychotherapy or neurotherapy sessions allowed before a mental health provider must submit an authorization request for additional treatment.

At a meeting Thursday, Nevada Medicaid rescinded implementation of new prior authorization rules for psychotherapy and neurotherapy that would have gone into effect on Oct. 1. The policy is expected to be officially reversed on an Oct. 25 meeting.

Designed to curb fraud, the new rules would have required mental health providers to submit a written request for prior authorization after five therapy sessions, down from the current limit of 18 sessions for adults and 26 for children.

During the meeting, Cody Phinney, deputy administrator for Nevada Medicaid, said the decision to revert back to the old limit will be accompanied by efforts by the department to monitor the quality and cost of care and that new arrangements to meet those goals will be worked out over the next few months.

— Jacob Solis


Nevada Medicaid is beginning the process of rolling back the limits on therapy services it put in place last month, a policy it said at the time was aimed at curbing fraud and abuse within the system but that therapists said would lead to a reduction in access to mental health services for the state’s most vulnerable.

At a meeting Thursday afternoon, Medicaid plans to rescind implementation of a new prior authorization policy approved in August that requires 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 policy is slated to go into effect on Oct. 1.

Medicaid can’t officially revert the policy to what it was previously — a limit of 18 sessions for adults and 26 for children without prior authorization — until a hearing on Oct. 25 because of an open meeting law requirement that the state give the public 30 days notice before making changes to a policy. However, Medicaid’s compliance chief said in an email that the division can choose to not implement a policy if it is less restrictive to providers and recipients.

In short, the state will continue to enforce the 18 and 26 session limits until the policy can officially be amended next month, and providers can still request prior authorization for additional sessions beyond those limits.

Medicaid is also in the process of translating recommendations from a working group that met in late August and early September to address the state’s concern over fraud and abuse within the system while not limiting the ability of patients to receive services. Those recommendations include making additional fixes to the prior authorization process, determining a baseline for what is considered a regular session and clarifying what counts as “medical necessity.”

“The community really brought us some alternatives that we had not considered previously that were, in fact, more effective at addressing some of the quality issues and some of the budget issues and Administrator [Marta] Jensen was so generous to allow us that additional time to do that work group,” said Cody Phinney, deputy administrator under Medicaid.

Phinney said providers also offered suggestions to improve the credentialing process for neurotherapy, examine what services are covered under a certain Medicaid provider type and require that medication training and support be offered by a higher level of professionals, such as physicians, registered nurses and pharmacists, instead of para-professionals.

“These are ways that we can address both the quality issues that we’ve talked about in the past with people perhaps billing improperly,” Phinney said. “Much of that is not intentional but rather misunderstandings, and it helps us clarify all of that.”

The recommendations will have to go through the rulemaking process, which includes an initial workshop on the changes followed by a hearing at which the policy is actually adopted, before they can officially take effect, a process Medicaid officials say they expect to happen over the next couple of months. Phinney emphasized the importance of providers participating in the rulemaking process, particularly early on.

“It’s extraordinarily helpful when we get a lot of participation at the very first step, which is the workshop,” Phinney said. “I just can’t emphasize enough how helpful it is for us to hear from the field when we have those workshops and present a concept. If there are people who have alternative ideas, we’re really making an effort to make sure we hear those ideas and incorporate them as much as we can.”

Jake Wiskerchen, the founder and clinical director of Zephyr Wellness and one of the most outspoken providers about the prior authorization changes, said he still wishes that Medicaid had approached providers before it first presented the proposal to limit the number of sessions before requiring prior authorization in June. But he said that providers should be “encouraged” that Medicaid is coming to the table now.

“I’m very encouraged,” Wiskerchen said. “This shows the state of Nevada is responsive to its people. That’s not a common trait among most state governments, and we’re thankful they take their jobs seriously and handle this with a dignity and a professionalism that makes us proud to live here.”

Nevada Medicaid approves policy requiring prior approval after 5 therapy sessions

Vitality Unlimited provides substance abuse treatment in Elko

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.

Mental health providers concerned about proposed limits on therapy sessions for Medicaid patients without prior approval

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.”