LEARN Behavioral Unit Battles MassHealth to Block $943,000 ABA Clawback

BOSTON – Autism Spectrum Therapies, the LEARN Behavioral subsidiary that holds the private-equity-backed chain’s Massachusetts Medicaid contracts, asked a state court on Sept. 23 to block MassHealth’s demand for about $943,000 it was paid for autism therapy in 2024 and to get back the $117,000 it has already repaid under protest.

According to the complaint, the state’s claim to the money rests on a ratio: one hour billed under the code for a licensed analyst’s own face-to-face treatment of a child, which can include directing the technician, for every 10 hours a technician bills for direct therapy. The ratio appears in no regulation, and in none of the company’s plan contracts, the complaint says, though Carelon Behavioral Health, the administrator that sent most of the notices, says the specifications reach its contract through provider manuals incorporated by reference. MassHealth never told providers the ratio was a condition of payment, the complaint says, and it reviewed no individual claims or medical records before ordering its contracted health plans to collect; instead, it compared totals of paid billing units.

Even one of those plans, Point32Health, told MassHealth in writing that the method “may be flawed” before sending the company its own demand, according to the complaint, which says the plan had not started collecting when the suit was filed.

The clawback reached the state’s largest ABA providers and runs into the millions of dollars, the company says, and the plans have told it to expect a second round for 2025. MassHealth paid about $279 million for ABA for roughly 10,200 members in fiscal 2025, according to a draft annual report from the state’s Autism Commission.

LEARN Behavioral, based in Baltimore and majority-owned by Gryphon Investors since 2019, runs more than 100 centers in 17 states. In Massachusetts, it operates as Behavioral Concepts, or BCI, a Worcester company it acquired in 2017, according to the complaint and the company’s announcement; the complaint says LEARN consolidated its Massachusetts payer contracts under the Autism Spectrum Therapies entity in February 2020. The company is represented by Hooper, Lundy & Bookman; the lawyer who signed the filing, David Schumacher, spent eight years as deputy chief of the health care fraud unit in the U.S. Attorney’s Office in Boston.

Where the 10-to-1 Ratio Came From

The figure comes from a set of “performance specifications” for ABA that appeared on the Massachusetts Behavioral Health Partnership’s website in 2016. The 2016 document says providers “are expected to comply” with it and that authorized supervision hours are based on “one hour case supervision for every 10 hours of direct service.” It describes how supervision hours are approved; it does not say that missing the ratio makes paid claims subject to recoupment. By December 2023, the version Carelon eventually said applied to the 2024 claims called the one-in-10 ratio a minimum, according to the complaint. A copy of that version was not available for this report.

The ratio turned into a dollar figure in March 2024, when the state Inspector General estimated that MassHealth had overpaid ABA providers up to $17.3 million. The office attributed most of that, about $16.8 million, to technician hours billed above the 10-to-1 line; its analysis covered service data from Jan. 1, 2022, through Oct. 30, 2023, and flagged 108 of the 562 providers that served at least five MassHealth members in that period. The report calls the specifications “expectations imposed on entities that contract to provide specific ABA services” and, on the same page, says they “require” the one-per-10 minimum. It asked MassHealth to review its claims data and decide “whether overpayment recoveries can or should be pursued.”

Providers objected to the math within weeks. In an April 22, 2024, letter to Gov. Maura Healey, the Inspector General, and MassHealth’s leadership, the National Coalition for Access to Autism Services argued that the ratio was written for prior authorization, not payment, and that analysts bill supervision under several codes beyond the one the Inspector General counted.

In 2025, MassHealth ran its own version of that math on calendar 2024 claims, the complaint says. It compared paid hours under CPT 97153 (CPT is the Current Procedural Terminology system used for medical billing), the code for technician-delivered treatment, with paid hours under CPT 97155, the code for treatment with protocol modification delivered face-to-face by a licensed analyst or other qualified professional, which may include simultaneous direction of the technician. Under that method, the complaint says, a ratio between 10-to-1 and 19-to-1 made the technician hours above-the-line overpayments, and 20-to-1 or above made all of them overpayments; by MassHealth’s illustration, 150 technician hours against 10 analyst hours left 100 hours payable and 50 owed back. MassHealth ignored every other code an analyst might use to bill supervisory work, the company says. BreakingNewsABA reported the clawback and its tiers in June.

The specification itself was rewritten this year. The version updated Feb. 15, 2026, says supervision during a technician’s direct service with a member must be “no less than 10 percent of direct service hours and should not exceed 25 percent of direct hours without documented clinical rationale.”

The Plan That Objected in Writing

According to the complaint, the notices went out in February 2026 from Carelon, formerly Beacon Health Options, which in 2024 administered behavioral health benefits for WellSense, Fallon Health, Health New England, and the Massachusetts Behavioral Health Partnership, the state’s behavioral health contractor, and in April from Point32Health, which runs the Tufts Health Plan Medicaid line. Carelon’s first letter asked for $919,000 within 30 days; in May it cut the figure to $857,000 and gave the company 15 days to pay. Point32Health’s demand was $86,000 across 14 members.

Point32Health had already questioned the method in writing, according to the complaint, which quotes a Feb. 9, 2026, written response from the plan to MassHealth’s program integrity team: “Overall, we believe that MassHealth’s CY2024 audit methodology may be flawed and the findings and recommendations are inaccurate.” The plan wrote that another code, H0031-U2, which covers assessment and case planning by a licensed professional, “is a valid code to bill for ABA services rendered by a physician or other qualified health professional that indicates supervision has occurred,” that MassHealth had not made clear to providers or plans that only 97155 would count, and that “[t]he first notice of this methodology is through the overpayment notification.”

Carelon’s notice, the complaint says, rested on that incorporation and on MassHealth’s rule defining overpayments.

MassHealth held its position, and the plans, in the complaint’s telling, said the decision was not theirs to reverse. Point32Health’s April 6 notice told the company the state “maintained that procedure code 97155 was required to document LABA supervision of a behavioral technician,” using the initials for a licensed applied behavior analyst, and said it would likely apply the same method to 2025 claims. Carelon answered a provider group’s demand letter the same day by saying it was administering the recoupment at MassHealth’s direction and had no authority to cancel or suspend it, the complaint says. The plans would have absorbed the cost of any demand they declined to press, Point32Health told the agency, according to the complaint, which refers to the company as AST and the plans as MCEs.

“Thus, when AST has attempted to contest the recoupment, MassHealth has directed AST to the MCEs, and the MCEs have blamed MassHealth.” – Autism Spectrum Therapies complaint, Suffolk Superior Court (September 2026)

Between late February and late March, the company asked Carelon five times for the claim-level data behind the demand and says it never got it. Working from what it had, it says at least 80 of the 123 members in Carelon’s sample met the ratio once it counted all billable supervision. In June it paid $117,000 under protest. On Sept. 11, Carelon declined to reopen its numbers or to meet, the complaint says, and the suit followed 12 days later. Point32Health had not begun collecting as of the filing.

A Rule That Changed on July 31

The complaint’s central legal claim is that MassHealth enforced a payment rule it never adopted. The company argues the state cannot impose a rule like this without publishing it, taking public comment, and filing it as a regulation, none of which happened, so the ratio and the 97155-only test are “without legal effect.” It also invokes a Massachusetts law that generally bars retroactive denial of a paid behavioral health claim once 12 months have passed since the provider submitted it. After that, denials are allowed only in listed cases, including fraud, duplicate payments, services never delivered, and services not delivered in accordance with MassHealth regulations, and the company says no defendant has alleged any of them.

MassHealth amended its overpayment rule this summer. On July 31, 2026, revised billing regulations took effect, and the definition of an overpayment now includes payments for “services that do not comply with applicable program regulations or managed care performance specifications.” The prior version, in force since 2018 and through the 2024 claims and the February notices, did not mention performance specifications, although it already counted payments made while a provider was in breach of its provider contract, or without required records, as overpayments. The state proposed the change in November 2025, three months before the first notices went out, describing it as a clarification that managed care providers must follow the specifications in their plan contracts. The amendment does not mention ABA or a ratio, and the court must decide whether the earlier rules and contracts authorized the recoupment.

The Executive Office of Health and Human Services is named as a defendant, and Secretary Kiame Mahaniah and Medicaid Director Ryan Schwarz are sued in their official capacities; Schwarz took the job on June 8, after the notices had gone out. The complaint also names Carelon, those four entities, Point32Health, and Tufts Health Public Plans. As of Sept. 30, no defendant had filed anything, and the docket shows no lawyer for the state.

The case was accepted on Sept. 24 into the Superior Court’s Business Litigation Session, the court’s docket for complex commercial cases. The company is asking for a declaration that the method is invalid, a permanent injunction against further collection, return of what it has paid, and a jury trial; it has not sought emergency relief. No hearing has been scheduled. Point32Health’s April notice told the company to expect the same method on 2025 claims.

AT A GLANCE

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