MassHealth and Health
Safety Net:
2024 Annual Report
MassHealth’s Applied Behavior
Analysis Program – Service Providers
March 1, 2024
Jeffrey S. Shapiro, Esq., CIG
Inspector General
Office of the Inspector General
Commonwealth of Massachusetts
 March 1, 2024
Via Electronic Mail
The Hon. Maura Healey Kate Walsh
Governor of Massachusetts Sec., Exec. Office of Health and Human Serv.
Maura.Healey@mass.gov Kate.Walsh@mass.gov
The Hon. Ronald Mariano The Hon. Karen E. Spilka
Speaker of the House President of the Senate
Ronald.Mariano@mahouse.gov Karen.Spilka@masenate.gov
Matthew Gorzkowicz Michael Levine
Secretary, Exec. Office of Admin. and Finance Assistant Secretary for MassHealth
Matthew.Gorzkowicz@mass.gov Mike.Levine@mass.gov
The Hon. Michael J. Rodrigues The Hon. Aaron M. Michlewitz
Chair, Sen. Committee on Ways and Means Chair, House Committee on Ways and Means
Michael.Rodrigues@masenate.gov Aaron.M.Michlewitz@mahouse.gov
The Hon. Patrick M. O’Connor The Hon. Todd M. Smola
Ranking Minority Member Ranking Minority Member
Senate Committee on Ways and Means House Committee on Ways and Means
Patrick.OConnor@masenate.gov Todd.Smola@mahouse.gov
The Hon. Marc R. Pacheco The Hon. John J. Mahoney
Chair, Senate Post Audit and Oversight Chair, House Post Audit and Oversight
Marc.Pacheco@masenate.gov John.Mahoney@mahouse.gov
Steven T. James Michael D. Hurley
Clerk of the House of Representatives Clerk of the Senate
Steven.James@mahouse.gov Michael.Hurley@masenate.gov
The Hon. Bruce E. Tarr The Hon. Bradley H. Jones, Jr.
Senate Minority Leader House Minority Leader
Bruce.Tarr@masenate.gov Bradley.Jones@mahouse.gov
The Hon. Ryan C. Fattman
Ranking Minority Member
Senate Post Audit and Oversight
Ryan.Fattman@masenate.gov
Re: MassHealth’s Applied Behavior Analysis Program – Service Providers
Dear Governor Healey and Commonwealth Leaders:
Pursuant to Chapter 12A of the Massachusetts General Laws and Section 96 of Chapter 28 of the
Acts of 2023, enclosed please find the Office of the Inspector General’s (OIG) 2024 Annual Report,
MassHealth’s Applied Behavior Analysis Program – Service Providers.
Office of the Inspector General for the Commonwealth of Massachusetts 2|Page
 In 2023, I created the OIG’s Healthcare Division (HCD) to conduct the annual OIG studies of
Massachusetts Medicaid (MassHealth) and the Health Safety Net (HSN), as well as to review a wide variety
of public healthcare policy, delivery and access issues. The HCD’s oversight work seeks to identify
programmatic vulnerabilities within MassHealth and the HSN and develop recommendations for
improving internal controls and practices to prevent fraud, waste and abuse of public funds in these public
healthcare systems.
This year the HCD reviewed MassHealth’s Applied Behavioral Analysis (ABA) Program, which
provides treatment to MassHealth-eligible children diagnosed with autism spectrum disorder through
MassHealth-managed care entities (MCEs) like managed care organizations and accountable care
organizations. Specifically, the OIG reviewed whether service providers deliver ABA treatment in a manner
consistent with MassHealth’s performance specifications.
The HCD determined that despite provisions in contracts with MassHealth, the MCEs did not
employ robust program integrity measures to ensure (1) that children on MassHealth received properly
supervised treatment, and (2) that overpayments to providers that submitted claims for unsupervised
services were identified, reported to MassHealth and ultimately recouped.
I want to thank the many contributors to this report, especially Gregory Matthews, Director of the
Healthcare Division. I also extend my appreciation to Susanne O’Neil, Acting Deputy Inspector General and
General Counsel; Alyssa Tasha and Stephen Gerry of the Data Analytics Division; Joshua Giles, Director of
the Policy and Government Division; senior executive assistant Nataliya Urciuoli; and the OIG’s
communications and publications teams.
Please contact me if you have any questions about this report or the OIG’s Healthcare Division. I
hope that you, too, find this report to provide meaningful and important insight.
Sincerely,
Jeffrey S. Shapiro, Esq., CIG
Inspector General
cc (via email):
Jane Ryder, Commissioner, Department of Developmental Services
Laura L. Schaub, Cataloger, State Library of Massachusetts
Susanne M. O’Neil, Acting Deputy Inspector General and General Counsel, OIG
Gregory H. Matthews, Director, Healthcare Division, OIG
Joshua Giles, Director, Policy and Government Division, OIG
Nataliya Urciuoli, Executive Assistant to the Inspector General, OIG
Office of the Inspector General for the Commonwealth of Massachusetts 3|Page
 INSPECTOR GENERAL’S COUNCIL
Susan Terrey, Elected Chair – By designation of Secretary of Public Safety and Security
Michael Leung-Tat, Elected Vice Chair – By designation of State Auditor
Amy Crafts – By designation of Attorney General
Comptroller William McNamara – By statute
Michael Caira – By Governor’s appointment
Rachel Ciocci – By State Auditor’s appointment
James Morris – By Attorney General’s appointment
Christopher Walsh – By Governor’s appointment
OFFICE OF THE INSPECTOR GENERAL ’S LEADERSHIP
Jeffrey S. Shapiro, Esq., CIG, Inspector General
Susanne M. O’Neil, Esq., Acting Deputy Inspector General and General Counsel
Gregory H. Matthews, Esq., Director, Healthcare Division
Katie Verma, Chief Operating Officer
Marcelle Payen, Chief Fiscal Officer
Sarah Hoover, Director of Human Resources and Recruitment
Office of the Inspector General for the Commonwealth of Massachusetts 4|Page
 TABLE OF CONTENTS
Executive Summary....................................................................................................................................... 6
Background ................................................................................................................................................... 9
I. The Office of the Inspector General’s Healthcare Division .............................................................. 9
II. The Medicaid Program ..................................................................................................................... 9
III. The Health Safety Net Program ..................................................................................................... 10
IV. Autism Spectrum Disorder ............................................................................................................. 10
V. Evolution of ASD Insurance Coverage in Massachusetts ............................................................... 12
Applied Behavior Analysis Treatment and Intervention ............................................................................. 14
I. Applied Behavior Analysis .............................................................................................................. 14
II. Recent Growth in the Applied Behavior Analysis Industry ............................................................ 15
Review of MassHealth ABA Services and Required Supervision ................................................................ 19
I. ABA Services Provided by MCEs and Their Provider Networks ..................................................... 19
II. MCE Staffing Requirements ........................................................................................................... 20
III. MCE Performance Specifications ................................................................................................... 21
IV. Supervision Requirements ............................................................................................................. 21
V. Tech-to-LABA Time Ratio for Supervision ...................................................................................... 22
VI. Methodology.................................................................................................................................. 23
VII. Outlier Review Findings ................................................................................................................. 24
Review of MassHealth ABA Program Integrity measures ........................................................................... 30
I. Importance of Program Integrity Measures .................................................................................. 30
II. Incentives for Preventing, Identifying and Reporting Fraud in Provider Networks....................... 30
III. MassHealth’s 2023 Contracts with MCEs ...................................................................................... 31
IV. Program Integrity Review Conclusions .......................................................................................... 35
Conclusions and Recommendations ........................................................................................................... 38
Appendix A: Abbreviations ......................................................................................................................... 40
Appendix B: MassHealth ASD Insurance Costs from 2021 to 2023 ............................................................ 41
Appendix C: MassHealth Members receiving ABA Treatment from 2021 to 2023 .................................... 42
Office of the Inspector General for the Commonwealth of Massachusetts 5|Page
 EXECUTIVE SUMMARY
The Office of the Inspector General’s Healthcare Division (HCD) has completed an analysis of
MassHealth’s Applied Behavior Analysis (ABA) Program, which provides treatment to MassHealth-eligible
children diagnosed with autism spectrum disorder (ASD) through MassHealth-managed care entities
(MCEs) like managed care organizations and accountable care organizations.1 The HCD sought to
determine whether service providers deliver ABA treatment in a manner consistent with MassHealth ABA
performance specifications. Those specifications require ABA providers within the MCE healthcare
networks to ensure that licensed applied behavior analyst (LABA) staff provide adequate supervision to
all paraprofessional staff, including behavioral technicians (BT) and interns, who administer adaptive
behavior treatment plans developed by the LABA and provide direct services to children with ASD. LABAs
provide BTs with a minimum of one hour of supervision for every 10 hours of direct ABA services. In
Massachusetts, to satisfy the licensure requirements for an LABA, a clinician must pass the Board Certified
Behavior Analyst (BCBA) examination issued by the Behavior Analyst Certification Board.2
As outlined in this report, the HCD conducted an outlier analysis that identified MassHealth ABA
providers that did not give access to adequately supervised ABA services for MassHealth members with
autism. As a result of gaps in program integrity reviews, MassHealth:
(1) overpaid MCEs’ ABA providers for service claims over the 10:1 supervision ratio in the amount
of $16,761,445;
(2) paid 627 ABA claims submitted by MassHealth providers that “impossibly billed” more than
24 hours of service for a member on a given date, resulting in overpayments of $439,632; and
(3) paid 561 ABA service claims purportedly provided to 311 members on holidays, amounting to
$162,535.
1 The OIG is aware that some members of the ASD community prefer to use terms such as “person with autism,” “person with
ASD,” “autistic person” or “person on the autism spectrum,” while others favor the use of other terms or embrace the concept
of neurodiversity to recognize that conditions like autism are neurological variations that are simply part of human differences.
The OIG seeks to not only promote person-first language but also an awareness that language changes with time and individuals
within groups sometimes have different opinions about the preferred language or terms used to describe themselves. For the
purposes of this report, the terms “autism spectrum disorder” and “ASD” are used when referring to the condition defined by
the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The
terms “children with ASD” or “children identified with ASD” are also often used throughout this report in accordance with Center
for Disease Control and Prevention guidance on person-first language. See
https://www.cdc.gov/ncbddd/disabilityandhealth/materials/factsheets/fs-communicating-with-people.html (last visited
February 22, 2024).
2To satisfy LABA licensure requirements, a clinician, pursuant to Section 165 of Chapter 112 of the Massachusetts General Laws,
must demonstrate good moral character; complete a doctoral or master’s degree program related to the study of behavior
analysis or a related field of human services; complete a practicum or supervised experience in the practice of behavior analysis;
and complete board-approved examinations, including the BCBA examination issued by the Behavior Analyst Certification Board.
See 262 CMR 10.03 and 10.04.
Office of the Inspector General for the Commonwealth of Massachusetts 6|Page
 These findings represent an opportunity for MassHealth and its ABA provider networks to conduct
program integrity audits to determine if services were actually rendered or accurately documented for
claims processing.
The HCD also determined that despite provisions in contracts with MassHealth, the MCEs did not
employ robust program integrity measures to ensure (1) that children on MassHealth received properly
supervised treatment, and (2) that overpayments to providers that submitted claims for unsupervised
services were identified, reported to MassHealth and ultimately recouped.
Office of the Inspector General for the Commonwealth of Massachusetts 7|Page
REPORT IN BRIEF
MassHealth Applied Behavior Analysis Provider Review
Why the OIG Conducted a Review of MassHealth Applied Key Findings
Behavior Analysis Providers
The OIG’s outlier analyses determined that:
Autism spectrum disorder (ASD) is a developmental disorder that affects • 1,831 MassHealth members received inadequately supervised
people’s ability to process information, causing (1) obstacles with social and ABA services;
communication skills, (2) restrictions in interests, (3) repetitive behaviors, • 108 providers provided inadequately supervised ABA services
and (4) sensitivity to, or discomfort from, sensory stimulation.3 and MassHealth overpaid for these ABA services in an amount
exceeding $16.7 million. The top 10 providers in this category
Applied behavior analysis (ABA) focuses on the analysis, design and account for $7,301,341 in overpayments;
evaluation of social and other environmental modifications to produce • MassHealth paid for 627 ABA claims representing more than 24
meaningful changes in human behavior. ABA services provide behavioral hours of service billed for a person with ASD on a given service
assessments, behavior-analytic data interpretation, highly specific treatment date (“impossible billing”). MassHealth’s payments for
plans, supervision and coordination of interventions, and training for other impossible billing totaled $439,632; and
interveners to address objectives or performance goals that support the • MassHealth paid 561 ABA claims for 311 members for services
acquisition of socially significant adaptive skills and reduction of behaviors purportedly delivered on holidays, amounting to $162,535. This
that interfere with a young person’s successful functioning. 4 finding represents an opportunity for MassHealth and its ABA
provider networks to conduct program integrity audits to
A review of ABA providers was necessary because over the past several determine if services were actually rendered on holidays or
years, the Office of the Attorney General’s Medicaid Fraud Division accurately documented for claims processing.
investigated and resolved numerous cases alleging ABA providers submitted
fraudulent claims to MassHealth for services not rendered and inadequate
supervision. Access to quality MassHealth ABA treatment for children is a
priority requiring that ABA services be provided by properly credentialed
licensed applied behavior analysts and behavior technicians or
paraprofessionals meeting minimum supervision standards.
OIG Methodology Conclusions
The OIG r