Nevada Medicaid is pausing enrollment for two types of behavioral health-care providers beginning Saturday while the agency develops new rules aimed at curbing fraud and abuse within the state-run insurance program.
For the next six months, Medicaid will not enroll any new lower-level mental health providers, known in Nevada as Qualified Mental Health Associates and Qualified Behavioral Health Aides, as it seeks input on what additional qualifications or oversight should be imposed on them. The moratorium comes amid Medicaid’s ongoing effort to respond to an executive audit earlier this year that identified inappropriate billing practices for behavioral health-care services and in the wake of intense backlash against state efforts to limit certain therapy services.
Medicaid Acting Administrator Cody Phinney said that under the existing rules, mental health associates and aides may not have the experience or training needed to carry the responsibilities of their positions. She said that the moratorium will give the state some “breathing room” as it rethinks how it certifies the lower tiers of mental health providers.
“It’s not that people are malicious, but if they don’t have adequate training, they may be doing something that they think is helpful that isn’t helpful,” Phinney said.
Phinney said Medicaid decided to examine possible changes to the two provider types after a series of focus groups this summer highlighted issues with the less-than-stringent requirements on certain mental health professionals. The focus groups were a direct response to outcry over a short-lived proposal to require psychologists, therapists and other mental health professionals to provide extensive documentation to the state in order to offer more than three therapy sessions with a patient.
“This was part of the information that was reflected to us from providers in the community, that what we really needed were some stronger, more specific requirements for people as they come into the field,” Phinney said.
As of Nov. 1, there were about 1,600 Qualified Mental Health Associates and 1,200 Qualified Behavioral Health Aides certified with Medicaid, according to data provided by the state. The moratorium will not affect already enrolled providers so long as they re-enroll on time, Phinney said.
Under the current model, Qualified Mental Health Associates function as “extenders” for therapists, Phinney said. They are responsible for identifying issues with patients, participating and developing treatment plans, and even providing parenting skills training, and are required to be licensed as a registered nurse or hold a bachelor’s or associate’s degree in a related field with some additional requirements.
On a lower tier are the Qualified Behavioral Aides, who are only required to complete 16 hours of training and hold a high-school degree to be certified. Phinney said the aides are supposed to provide direct assistance to patients under the supervision of a higher-level professional, but that Medicaid has found that its policy wasn’t specific enough in outlining the qualifications for those individuals.
“It has been interpreted more loosely,” Phinney said. “We need to make sure we are clear about what it is we need and expect and that we have enough capacity to oversee things so that it’s not wasteful and everybody is safe. Our big concern is that everybody is safe and everybody is getting services that really accomplish the goal.”
Phinney said that “everything is on the table” as it relates to potential changes to the two provider positions, though she highlighted Washington as a state Nevada could possibly model itself after. Washington requires workers who fall into two provider categories similar to Nevada’s to pass state-approved exams and complete extensive training, and also limits the scope of practice for each type of worker.
“We’re very sensitive to the fact that we want feedback from the community about how to do this right for Nevada … This is one path,” Phinney said. “But we really want to come up with what works best for Nevada.”
She said that Medicaid will have additional public meetings to craft a proposal, but that it is also planning to lean on the Bureau of Health Care Quality and Compliance and the state’s various licensing boards for guidance. Phinney expects that the process will take Medicaid the full six months of the moratorium, though she said it’s possible Medicaid could reach a solution sooner.
Until the moratorium is lifted, no new providers will be able to enroll with the state, something Phinney said is designed to prevent providers from enrolling with either provider type only to be disqualified a few days later but also to give the state time to design an appropriate fix.
She said the state also has mechanisms in place that would allow it to consider provider applications on a case-by-case basis as to not create a problem with access to services. Over the last year, Nevada enrolled an average of about 20 Qualified Mental Health Assistants and about 21 Qualified Behavioral Aides a month, according to state data.
In addition to the moratorium, Phinney said Medicaid is working through other changes recommended by the focus groups, including revisions to enrollment for certain kinds of therapy services and clarifying policies with providers.
“We’re seeing a lot of good outcomes from that, as far as things becoming more clear and more consistent,” Phinney said. “We certainly want to hear from anybody who is having challenges, and we are available to help them work through any challenges.”
ELKO – Teamwork, technology and textbook management techniques.
Those are some of the methods applied by Elko County District Attorney Tyler Ingram in the DA’s office within the past two years, leading to an overhaul of the caseload management system and reducing pending cases below 200.
Ingram made the announcement to the Elko County Commissioners in an email praising his office’s efforts in attaining the goal.
“I think it’s well-justified that I share praise for our amazing employees in my office,” Ingram wrote, pointing to his staff of eight deputy district attorneys, seven caseworkers and seven support and administration personnel.
The office — which handles all of Elko County’s criminal and civil cases — brought the amount of pending cases, once averaging more than 600, down to 183. As of Oct. 23, the office had a total of 4,109 cases assigned to attorneys and staff for court action.
The accomplishment in the DA’s office comes two years after Ingram’s appointment when he set the goal to bring pending cases – those of which are awaiting additional information before they are assigned to a deputy district attorney – below 200, even as the office receives new cases from all law enforcement agencies throughout the county, including state enforcement agencies.
Ingram said he was aware of how the public perceived the DA’s office, due to the backlog.
“I talked to lots of people in preparation for my interview with the commissioners,” Ingram said recently. “One of the most common conversations I had [with people] was about the backlog of cases. So, it was obviously a concern for the public.”
“As far as I know, this is the lowest number of pending cases that we have ever had during my employment with Elko County,” said Ingram, who has been a prosecutor in the DA’s office since 2011. He said the next goal for the office is have 150 or fewer.
Elko County Commissioner Delmo Andreozzi called the accomplishment “a milestone” that recognizes the employees’ hard work.
“He’s eager to perform better, and I applaud those kinds of efforts,” Andreozzi said. “He didn’t do it single-handedly, but with a qualified team of professionals in his office.”
To start, Ingram divided the office into two teams of deputy district attorneys and caseworkers who separately handle misdemeanors and felony cases. Implementing teams also gives the more serious cases to experienced attorneys, with murder and child abuse receiving top priority.
“I thought it was a better use of county resources to devote our most difficult cases to more senior attorneys,” Ingram said, recalling that in the past deputy district attorneys handled misdemeanors, gross misdemeanors and felonies in their workload, regardless of experience.
Although the office has not always been fully staffed, Ingram credited the personnel for taking up the slack when a prosecutor recently moved out of the area.
“We hit that 183 mark down an attorney,” Ingram said.
Developing open communication channels among law enforcement has also contributed to a more efficient case flow, Ingram explained.
“We put a substantial amount of effort into making sure that we are working well with all the law enforcement, and that’s key because when you have a good working relationship things flow so much more smoothly,” Ingram said, adding that the office’s communication and relationship building is also a priority with defense counsel, the public defender’s office and the courts.
Elko County Commissioner Cliff Eklund, who was on the board when Ingram was appointed, said he believes Ingram “has done a very good job” within the past two years.
“I think Tyler has done a great job prioritizing cases. Especially crimes against children by putting it on top of the priority list,” Eklund said.
Andreozzi said he thought the speedier movement of cases through the courts is beneficial to the victims, especially children.
“[To] prioritize crime against children is appropriate. These are victims, and until they get that time in court and the perpetrators are tried, [the victims] are continuing to be victimized,” Andreozzi said.
“It is mind-boggling how many cases they go through,” Andreozzi continued. “It’s unfortunate of the volume, but I’m grateful they’re trying to get through the system and that’s in the best interest of the victims.”
As the office reorganized to meet that one objective, Ingram said the deputy district attorneys are striving to balance time and efficiency with the “ethical duty to do what is right.”
As part of the restructuring efforts Ingram drafted an office policy stating that “a guilty verdict is not a win and a not guilty verdict is not a loss.”
“Our goal is never to get a conviction,” Ingram said. “Our goal is to do what is right.”
“Sometimes doing what is right means a conviction,” he continued. “We believe morally, ethically that a conviction is justice. But sometimes, a conviction is not justice. Sometimes it is allowing or agreeing for someone to enter drug court instead of suffering a felony conviction for possessing methamphetamine.”
Ingram, who was elected to a four-year term on Nov. 6, said he understands that people may not agree with the way a case is handled, but he hopes that by letting the public know he is accessible and willing to answer questions, it might resolve some questions that individuals may have about the legal process.
Although there are some exceptions, “for the most part I can answer any questions or talk about their concerns with them,” Ingram said, adding that he always keeps in mind that he and his office are public servants.
“My opinion is that we work for everybody.”
ELKO – Green racks shaped like bicycles have been popping up all over town. Now cyclists can lock up in style.
“Bikers previously locked them to whatever object was nearby,” said project coordinator and Elko Velo member Mikaella Rough. “Garbage cans aren’t always the most sanitary place to lock a bike. The bike-shape racks send a positive message about biking and provide a safe location for bicyclists to lock their bikes where they can feel safe that they will not be stolen.”
Elko Velo is a nonprofit bike group. Members “provide and promote a wide range of organized cycling opportunities for road and mountain bicyclists.”
The group saw the need to provide bike racks in the community and formed the project. Thirteen racks have been placed in the downtown, the Elko Junction shopping plaza and at the retail strip on Idaho between Quiznos and Dairy Queen.
“We have received a lot of sponsorship support,” Rough said.
Fourteen groups sponsored the purchase of the 13 racks. Each rack lists the main sponsor for that particular structure.
Rough said they add an attractive addition to downtown.
“We chose a lovely hunter green color to match the benches around town and because it is a nice outdoorsy color and semi-neutral,” she said.
ELKO – Two months after a devastating wildfire swept into Lamoille Canyon, residents and visitors were allowed back in – but not very far.
On Dec. 1, the U.S. Forest Service allowed the public to access the Powerhouse Picnic Area and Talbot Trailhead at the base of the canyon.
The Lamoille Canyon Scenic Byway will remain temporarily closed approximately three miles above the junction of Lamoille Highway.
“We are excited to be reopening a little bit of the closed area to the public,” said District Ranger Josh Nicholes. “We recognize how important this area is to our community and we are working as fast as we can to make the area safe again and open to the public.”
The canyon was closed for a two-month period due to the 9,000-acre Range 2 Fire, which started Sept. 30 near the Spring Creek shooting range. The Forest Service is extending the closure through the end of December 2018, while work is being done to mitigate rockfall hazards and rebuild destroyed guardrails along the roadway.
The Ranger District will continue to revisit the remaining closure area to see if additional sections can be reopened.
“When we get enough snow to support snowmobiling activity we will evaluate conditions and look at relaxing the closure to accommodate winter sports activities,” added Nicholes. “We appreciate the public’s patience in staying out of the closed area until we can mitigate the safety hazards.”