Press Release  Inspector General Estimates MassHealth Overpaid Up to $17.3 Million to Service Providers for Children With Autism

Boston, MA — The Office of the Inspector General’s Healthcare Division estimates that MassHealth overpaid up to $17.3 million in claims to service providers for children diagnosed with autism spectrum disorder (ASD), due, in part, to a lack of robust internal reviews. The assertions are contained in the OIG’s recently released MassHealth and Health Safety Net 2024 Annual Report, “MassHealth’s Applied Behavior Analysis Program – Service Providers.”

MassHealth’s Applied Behavior Analysis (ABA) Program provides treatment to MassHealth-eligible children diagnosed with ASD. MassHealth requires ABA providers to ensure that licensed applied behavior analyst (LABA) staff supervise all paraprofessional staff a minimum of one hour for every 10 hours of direct services. The OIG’s investigation found that ABA providers billed and MassHealth paid claims for services that did not meet the required 10:1 supervision ratio in the amount of $16,761,445.

“The failure to ensure that ABA services are properly supervised undermines the reliance that families place in MassHealth to deliver the highest quality of services for their children,” Inspector General Jeffrey S. Shapiro said. “It is equally concerning that ABA service providers billed for services that did not meet MassHealth’s supervision standard, resulting in a lower level of service for children with ASD who are on MassHealth. That is unacceptable.”

Additionally, the OIG found that MassHealth made payments of $439,632 to ABA providers that were indicative of “impossible billing” (more than 24 hours of service for a member on a given service date), and that MassHealth paid 561 ABA service claims purportedly provided to 311 members on holidays (Christmas, July 4th, etc.), amounting to $162,535.

The OIG conducted a secondary review to assess MassHealth’s oversight and its internal controls to identify, prevent and recover improper payments. The OIG found MassHealth’s new contracts contain financial incentives for service providers to institute more robust controls to mitigate and identify fraud, waste and abuse. However, opportunities still exist to ensure that MassHealth members with ASD receive properly supervised services. For example, MassHealth has not conducted an audit of ABA Managed Care Entities since MassHealth began covering ABA services in 2015.

Finally, the lack of qualified licensed applied behavior analysts (LABA) who supervise the services provided to children diagnosed with ASD is a real problem and not one that MassHealth can solve on its own. “Expansion of loan forgiveness programs designed to attract and retain individuals to pursue careers in healthcare, particularly those in underserved communities, should consider including LABAs as an eligible profession,” IG Shapiro said. “Still, in spite of the shortage, failure to follow supervisory standards is unacceptable.”

The OIG is required to perform annual reviews of MassHealth and the Health Safety Net to identify vulnerabilities within these public healthcare systems and develop recommendations for improving internal controls and practices to prevent fraud, waste and abuse of public funds.

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