Some Massachusetts autism therapy providers may face significant Medicaid payment recoupment as the state seeks to recover payments it made in 2024 that weren’t in line with a treatment-to-supervision ratio that many industry insiders dispute.
Starting in February, officials with the Massachusetts Executive Office of Health and Human Services (EOHHS) and MassHealth (its Medicaid program) directed its contracted managed care organizations to recoup 2024 Medicaid payments from organizations that did not maintain a ratio of 10 hours of paraprofessional therapy to 1 hour of supervision by a Licensed Applied Behavior Analyst (LABA), the state’s name for Board Certified Behavior Analysts (BCBAs).
State associations and provider organizations have pushed back against using this ratio as grounds for recoupment. They see the ratio as a clinical guideline, not a condition of payment or grounds for recoupment. They also said the timelines for some specific recoupment efforts are unreasonable.
In a legal demand letter, attorneys for Massachusetts Providers for ABA Access and Quality (MPAAQ) and the Massachusetts Association of Applied Behavior Analysis (MassABA) calls the recoupment effort “egregiously flawed, both as a matter of substance and process.
“Having sprung the recoupment on the ABA providers out of nowhere and selecting an arbitrary and absurdly immediate date for recoupment before the ABA providers’ opportunity to appeal has even run, the ABA providers are not able to get even the most basic information about the audit process,” the letter reads.
The effort to recoup payment has stalled as the state, its MCOs and providers work through several questions related to the recoupment effort. Multiple providers BHB has communicated with say that claims payments continue to be delivered as expected; they have not received additional demands for recoupment payments.
Medicaid recoupments such as this could have devastating effects on autism therapy providers, who often take on additional risk by seeing Medicaid patients. Autism therapy organizations are also not known for holding much cash on their books, as much of every individual claim payment goes to the clinician providing care. What’s more, recoupment efforts based on disputed interpretations of regulations erode providers’ confidence in operating in the state.
“What you’ll end up finding is folks will say, ‘This isn’t feasible anymore — to do Medicaid services,’” one executive based in the state told BHB. BHB is not naming the provider, who fears repercussions. “So who gets impacted by this? It’s the low-income families that already face such difficult access to health care services. They’re the ones who end up getting impacted because a provider can and will likely be forced to start to think about like, ‘Can I survive here?’”
The executive noted that patients and provider organizations must go through prior authorization processes before services start, renew authorization for treatment every six months, and undergo claims review before they get payment for services rendered, a process that can take months.
“It just makes you really nervous about what other rules they can retroactively create to then turn around and tell you all of these claims from two years ago are subject to 100% recruitment,” the executive said.
Generally, supervision is a loosely used phrase that applies to BCBAs’ oversight of care provided by paraprofessionals, treatment planning, treatment data analysis, and other activities as well as actions that are related and allowed to be billed. From a billing perspective, supervision — more specifically, protocol modification — occurs when a BCBA is face-to-face with a technician and the patient, one of the points autism therapy providers dispute.
“It is an incomplete view of supervision, and moreover, to now say, ‘We’re going to hold you to something that we didn’t tell you [for which we] could take dollars back from’ has everybody worried,” Jim Spink, CEO of New York City-based Autism Care Partners, told BHB. “If you’re a small provider, and you suddenly have a six-figure recoupment from 2024, you will not make payroll. We have had smaller providers say that if they do not get a reprieve here, they cannot take more MassHealth members.”
Tufts Health Plan, a payer that offers two managed care plans, and Carelon Behavioral Health, which handles behavioral health benefits on behalf of several MCOs in the state, sent providers letters detailing a directive from MassHealth to recoup 100% of payments made that fall outside of the 10-1 ratio, or 10%, if an organization’s overall ratio of therapy to supervision is less than 5%, or 20-1. Organizations with a ratio between 5% and 10% face partial recoupment.
Carelon Behavioral Health, a part of Elevance Health (NYSE: ELV), also partners with the Massachusetts Behavioral Health Partnership, the state’s direct care plan.
The letters state they are operating on behalf of MassHealth and refer to the state’s citation of an audit it released in March 2024. That audit estimates that MassHealth overpaid autism therapy providers $16.8 million for services that exceeded the ratio.
The recoupment letters from Tufts Health Plan and Carelon Behavioral Health, obtained by BHB, show varied approaches by the two MCOs. Tufts’ letter informed providers of potential recoupment but also stated that it had several methodological questions related to the recoupment and the 2024 audit and would be seeking clarification. It also stated that Tufts was unclear on the use of the supervision ratio rule and how it was accounted for in claims data.
“Center-based services are always supervised, with LABA typically within arm’s reach of the behavior technicians,” the letter states.
Carelon Behavioral Health, on the other hand, said recoupment payments must be made in full within 30 days of when the notice was issued. Representatives of Carelon Behavioral Health have declined to comment.
In another letter obtained by BHB, Tufts Health Plan went further, raising several issues with state officials over the recoupment effort, the 2024 audit, and the state’s practices around billing and the treatment-supervision ratio. It also points out that many health plan systems are not able to determine ratios in claims adjudication without manual counts.
“Penalizing health plans and ABA providers for poorly codified supervision ratios via recoupment of funds is not the solution and sends a discouraging message,” the letter states. “Instead, EOHHS should work with ABA providers, local and national trade organizations, and health plans to design a set of ABA service delivery and billing requirements that are informed, clearly communicated, codified, and not rely on manual counting of visits/claims.”
MassHealth is one of many states that are under pressure from the federal government over how they have handled their Medicaid spending, especially around autism therapy.
In March, the U.S. House Committee on Energy and Commerce demanded that 10 states turn over information about how they handle fraud, waste and abuse (FWA). The letter cites autism therapy as a specific area of concern.
Through its Office of Inspector General, the U.S. Department of Health and Human Services has found that several states made improper and potentially improper payments to autism therapy providers that total $599.8 million. The audit series so far has also found that the autism therapy industry generally has a massive problem with claims and treatment documentation.