The First Provider to Sue
On September 23, Autism Spectrum Therapies (AST), a unit of LEARN Behavioral, filed a lawsuit to stop Massachusetts from clawing back payments for ABA services it delivered in 2024. Behavioral Health Business reported the complaint on September 28.
The defendants are ten parties: the Executive Office of Health and Human Services, EOHHS Secretary Dr. Kiame Mahaniah, MassHealth Director Dr. Ryan Schwarz, Carelon Behavioral Health, Point32Health, WellSense Health Plan, Fallon Community Health Plan, Health New England, the Massachusetts Behavioral Health Partnership, and Tufts Health Public Plans.
The money:
- $943,000 in total recoupment sought from AST
- $857,000 of that through Carelon Behavioral Health
- $86,000 through Point32Health
- $117,000 already paid under protest, which AST wants returned
“MassHealth’s shortsighted action will drive ABA providers out of business and risks the financial stability of [Autism Spectrum Therapies],” the complaint says, according to BHB. The state, AST, and the health plans did not respond to BHB’s requests for comment.
LEARN Behavioral is a large national provider and can afford to litigate. The reason every practice should pay attention is the calculation behind the demand, because it can be run against any provider’s claims without opening a single chart.
Where the 1:10 Ratio Came From
MassHealth’s position is that ABA providers must ensure licensed staff supervise paraprofessionals for at least one hour for every 10 hours of direct service.
That position got teeth in March 2024, when Massachusetts Inspector General Jeffrey S. Shapiro estimated that MassHealth overpaid ABA providers by up to $17.3 million. Most of it, $16,761,445, was for services that didn’t meet the 10:1 supervision ratio. The rest covered “impossible billing” of more than 24 hours of service on a single date ($439,632) and 561 claims for 311 members on holidays like Christmas and July 4 ($162,535).
“Failure to follow supervisory standards is unacceptable,” Shapiro said. His office also acknowledged the shortage of licensed analysts and recommended MassHealth audit its ABA managed care entities. According to the IG, none had been audited since ABA coverage began in 2015.
AST’s lawsuit challenges the foundation. It argues the 1:10 ratio comes from a 2016 “aspirational guidance document” that was never put through formal rulemaking. Breaking News ABA reported in June that provider groups trace the requirement to performance specifications, not regulations. MassHealth and Carelon couldn’t produce the 2024 specifications, only a version dated January 1, 2025. The ABA regulation, 130 CMR 358.00, doesn’t clearly define the supervision requirement.
How the Recoupment Math Works
This is the part to understand even if you never bill MassHealth.
According to Breaking News ABA, the calculation used 2024 managed care claims and compared two codes:
- CPT 97153: adaptive behavior treatment by a technician
- CPT 97155: adaptive behavior treatment with protocol modification by a qualified professional
The ratio of paid 97153 units to paid 97155 units was computed child by child, for each provider, across the full calendar year:
- 10:1 or better: no recoupment
- Between 10:1 and 19:1: recoupment of the direct therapy hours above the 10:1 line
- 20:1 or worse: recoupment of all direct therapy delivered to that child
Notices started going out in late February 2026, many with 30-day payment deadlines. Breaking News ABA reported that one provider had money withheld from claims a few days before its deadline.
Why Providers Say the Method Is Wrong
AST argues the methodology compares only two billing codes, even though other supervision-related activity exists outside that comparison. Point32Health/Tufts itself filed a formal dispute on February 9, citing methodology flaws and gaps in how supervision is coded. Two provider groups, MPAAQ and MassABA, called the recoupment “egregiously flawed, both as a matter of substance and process” in a demand letter.
The underlying problem is easy to see. Supervision of an RBT can happen in ways that don’t produce a 97155 unit: a BCBA observing without modifying the protocol, supervision a payer doesn’t reimburse separately, or 97156 parent training that also informs the technician’s work. A ratio built on 97155 alone treats all of that as if it never happened.
The other argument is fairness. The state paid these 2024 claims. Recouping them now, under a standard providers say was guidance rather than rule, means a practice can be fully compliant with what it was told and still owe money two years later.
“If you’re a small provider, and you suddenly have a six-figure recoupment from 2024, you will not make payroll,” Jim Spink, CEO of Autism Care Partners, told Breaking News ABA.
That’s the same failure mode we wrote about in July: Medicaid payment holds that close practices before anything is proven. A recoupment doesn’t need a fraud finding. It needs a ratio and a deadline.
This Isn’t Only a Massachusetts Problem
The 97153-to-97155 ratio is the cheapest supervision test there is. It needs nothing but claims data, and every state Medicaid agency and managed care plan has that.
Federal attention is already there. Supervision was a recurring finding in the HHS OIG state audits, and the CMS ABA toolkit from August encouraged states to strengthen supervision standards and claims analytics. Whatever happens to AST’s lawsuit, expect more agencies to compute a ratio like this one.
The defense has two parts. Know what your state actually requires, and be able to show your supervision with something stronger than one billing code.
What to Do This Month
1. Find out whether your state’s ratio is a rule. Look up the supervision requirement in your state Medicaid ABA policy, and in each MCO contract and provider manual. Note whether it’s in regulation, a provider manual, a performance specification, or guidance, and which version applied to which dates of service. If you can’t find the document for a given year, that’s worth knowing before an auditor asks.
2. Run the ratio yourself. Pull 97153 and 97155 units by child for each Medicaid payer for the last full year and the current year. Flag every child under your state’s threshold, and especially any at 20:1 or worse. This is the exact report an auditor will run, so run it first.
3. Document the supervision that doesn’t bill as 97155. For flagged children, check whether supervision happened in other forms: direct observation, team meetings, protocol reviews, parent training. Make sure each one has a dated supervision record naming the supervisor, the technician, and what was covered. Unbilled supervision you can document is an argument. Unbilled supervision you can’t document is a recoupment.
4. Fix the forward-looking gaps. If some children are under-supervised for real, the cause is usually BCBA caseload. We covered the math in BCBA caseload and billable hours. Rebalance before the ratio becomes a demand letter.
5. If you get a recoupment notice, don’t just pay it. Note the deadline and the appeal window, ask for the methodology and the standard it applies, and talk to a healthcare attorney. In Massachusetts, provider groups argued the appeal deadline was April 2. Paying under protest, as AST did, can preserve your right to contest.
Where Software Fits
The ratio an auditor computes from claims is a crude proxy. The best answer is a supervision record good enough that nobody needs the proxy.
In StreamABA, supervision assignments, supervision notes, and the supervision compliance and ratio dashboard show supervision for each technician and client as it happens, not after a payer computes it. Session notes tie each billed unit to the rendering clinician and the time of service, and authorization tracking shows units by code against what was approved. If a client’s ratio is drifting, you can see it in the current month instead of in a 2028 demand letter.
Want help running the 97153-to-97155 ratio against your own claims? Reach out at [email protected].
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Sources
- Behavioral Health Business: LEARN Behavioral Entity Sues to Stop MassHealth Medicaid Recoupment (September 28, 2026)
- Breaking News ABA: Massachusetts Claws Back ABA Payments Over Supervision Ratio (June 17, 2026)
- Massachusetts Office of the Inspector General: Inspector General Estimates MassHealth Overpaid Up to $17.3 Million to Service Providers for Children With Autism (March 5, 2024)
