The fast-growing autism therapy provider ABA Centers of America is claiming $80 million in a contract and payer ghosting lawsuit that it filed against Canton, Massachusetts-based Point32Health.
State court documents argue that Point32Health has underpaid claims for services that were authorized for certain patients and since December 2023 has not paid any ABA Centers of America’s claims. The lawsuit alleges ABA Centers of America claims submitted to Point32Health and its subsidiary Harvard Pilgrim Health Care, the only other named defendant in the suit, have been placed on “pend status.”
“We believe this lawsuit is necessary to attempt to halt the irresponsible and unreasonable behavior by Point32,” Christopher Barnett, founder and chairman of ABA Centers of America, said in a statement. “We have tried for months and months to partner with Point32 in order to provide adequate care to their subscribers.”
The company has continued to serve Point32Health members despite not getting claims paid.
“I refuse to allow these kiddos that desperately need our care to suffer by discharging them,” Barnett said. “Instead, I will muster up my resources and hold Point32 accountable on behalf of, not only the Point32 covered kiddos in my care, but the Point32 kiddos with autism all over the country that may not have the resources [that] I do to fight.”
These are not denials, nor are delays explained by the payer, the court documents state. The allegations in the suit mimic key attributes of the payer practice described to me previously as “payer ghosting.” Experts in the space describe it as payers simply doing nothing with a claim, often leaving providers in limbo without the specific recourse of denied claims.
“[Harvard Pilgrim Health Care and Point32Health] have never denied coverage for the services, nor disputed that the services are medically necessary,” the lawsuit states. “By placing plaintiff’s claims for ABA therapy services in ‘pend’ status for over a year, defendants have underpaid plaintiff for admittedly authorized and covered services rendered to defendants’ members/subscribers, including but not limited to those identified above.”
Point32Health has not commented on the matter. This story may be updated.
The allegations of delayed claims and underpaid claims reflect the tenuous relationship that many payers now have with autism therapy service providers. In many communities, timely access to autism diagnostics and autism therapy is a challenge given the relative shortage of providers due to the explosion in demand for such services over the last few years. This is allegedly at play in the dispute between ABA Centers of America and Point32Health.
ABA Centers of America claims that Point32Health’s autism therapy directory is inaccurate, giving the public a false impression of the actual size of and availability of care through the network. The suit claims that Point32Health operates what the health care industry informally calls a ghost network. This is a common problem within all of health care, especially for outpatient mental health, where many providers decide against joining networks to avoid what they see as underpayment and administrative burdens.
Some research finds that behavioral health-related insurance directories can be wildly inaccurate. In one study, researchers found that only 16% of listings had correctly listed phone numbers and only 28% had correct addresses. In another, researchers found that less than 18% of clinicians listed as in-network for Medicaid answered requests for appointments, accepted Medicaid and could provide a new patient appointment.
Point32Health has discussed access challenges before. The payer told BHB in 2024 that it had created a care navigation program for behavioral health because, in part, “it takes so much time for the average person” to find care through its network. Service navigators take up the legwork of calling providers to check availability after determining the patient’s needs and desires, according to Bill Harlan, vice president of behavioral health at Point32Health.
The lawsuit alleges violations of state law related to promissory estoppel and unjust enrichment. ABA Centers of America, according to the lawsuit, often sees patients on an out-of-network basis, should the patient’s benefits allow such care. Thus, the provider does not have a contract with the two insurers. Still, it claims that the members of Point32Health and Harvard Pilgrim Health Care are granted out-of-network coverage for autism therapy services.
It describes the care needs of seven unnamed pediatric patients treated by ABA Centers of America. Each apparently requires continued care for several issues, including destructive and self-injurious behaviors.
“Defendants are fully aware that its members are unable to access necessary services through in-network providers due to deficiencies, yet it continues to obstruct efforts to secure adequate reimbursement for out-of-network providers,” the lawsuit states. “Rather than honoring its obligations to its members and ensuring access to medically necessary care, Point32 withholds reimbursement, forcing Point32 subscribers and plaintiffs into an untenable position. This behavior not only jeopardizes patient care but also places an undue financial burden on providers and Point32 subscribers.”
Because many of ABA Centers of America’s claims are not denied, the lawsuit claims that the federal law Employee Retirement Income Security Act (ERISA), which is itself, along with the significant amount of case law around it, one of the most relevant laws in payer disputes, does not apply.
Fort Lauderdale, Florida-based ABA Centers of America, founded in 2020, grew its revenue over a three-year period ending in 2023 by 32,192%, according to the Inc. 5,000 list of the fastest-growing private American companies. It ranked No. 5 overall on the list and was the third-highest-ranked of all health services organizations.
