Unearthed data ignites fraud concerns amid Medicaid's $5B autism therapy boom
Federal prosecutors have charged providers with billing tens of millions for services allegedly never provided to children
{{#rendered}} {{/rendered}}Medicaid spending on a top autism therapy has exploded into the billions — drawing increased scrutiny over rising fraud within the system.
Applied Behavior Analysis (ABA) therapy is a lifeline for hundreds of thousands of American families. It helps children with autism develop communication, social and daily living skills. According to Department of Health and Human Services (HHS) provider spending data, Medicaid paid more than $5 billion over a six-year period.
And as Medicaid spending on ABA therapy has surged, so has scrutiny over how taxpayer dollars are being spent and whether its rife with fraud like many other government assistance programs.
{{#rendered}} {{/rendered}}In May, federal prosecutors charged two Minnesota autism clinic operators with allegedly billing Medicaid $46.6 million for services prosecutors say were unnecessary or never provided, including claims tied to children with allegedly fraudulent autism diagnoses.
Applied Behavior Analysis (ABA) therapy helps children with autism build communication, social and daily living skills through structured, one-on-one sessions. (iStock)
Earlier this year, another Minnesota woman pleaded guilty in a separate $14 million Medicaid autism fraud scheme.
{{#rendered}} {{/rendered}}Investigations by The Wall Street Journal and The New York Times have also documented allegations that some providers billed for services that were never provided, inflated therapy hours and aggressively expanded as Medicaid spending surged.
A partisan divide is emerging over how states should handle public assistance programs for the ballooning treatment option, especially as fraudster activity has come under a microscope in the federal government.
Republican-led states like Florida have prioritized fraud enforcement and tighter oversight, while debates in states like Georgia have centered on reimbursement rates and preserving access to care. The scrutiny comes as the Trump administration has made it a focus of his second term to eliminate fraud, waste and abuse across federal programs, including Medicaid, a central policy priority.
{{#rendered}} {{/rendered}}Supporters of stronger oversight argue that every dollar lost to fraud is money that cannot be used to provide care for children and families who depend on Medicaid-funded autism therapy.
MEDICAID FRAUD FEARS GROW AMID MASSIVE RED STATE BILLING SPIKE IN SECTOR THAT ALSO PLAGUED MINNESOTA
Republicans have argued that eliminating fraud, waste and abuse in Medicaid should be a priority before considering broader changes to the program, saying improper payments divert taxpayer dollars from vulnerable Americans who depend on the safety net. (Leigh Vogel/Getty Images for Caring Across Generations)
Between 2018 and 2024, Medicaid providers paid out more than $5.15 billion under one of the primary billing codes used for ABA therapy.
{{#rendered}} {{/rendered}}Three providers received roughly $685 million in Medicaid reimbursements during that period.
ABA therapy is one of the most common treatments for children with autism, using structured, one-on-one sessions to build communication, social and daily living skills.
Much of that therapy is delivered by Registered Behavior Technicians (RBTs), entry-level workers who complete a 40-hour training program and work under the supervision of Board Certified Behavior Analysts, whose job it is to design and oversee treatment plans.
{{#rendered}} {{/rendered}}Medicaid data identifies examples of providers receiving unusually large reimbursements under the ABA billing code, including some claims that equate to hundreds of dollars per minute of therapy based on a standard 15-minute billing unit. The data alone does not explain why those reimbursements were so high, and billing experts say unusually large payments can reflect a variety of factors, including claim adjustments or other administrative processes.
MINNESOTA FRAUD SUSPECT SKIPS COURT, FORFEITS BOND, THROWING $11M MEDICAID CASE INTO DOUBT
The Trump administration has made eliminating fraud, waste and abuse in Medicaid a central priority, calling on states to tighten oversight and remove fraudulent providers from the program. (Andrew Harnik/Getty Images)
The Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Medicaid in partnership with states, told Fox News Digital it has observed "significant growth" in Medicaid spending on ABA therapy in recent years.
{{#rendered}} {{/rendered}}"While access to medically necessary services remains a priority, rapid program growth also underscores the importance of ensuring services are clinically appropriate, delivered by qualified providers, and supported by strong program integrity safeguards," a CMS spokesperson said.
As concerns over fraud have grown, states have responded differently.
Florida says it recovered more than $72 million in improper Medicaid payments over the past year and prevented hundreds of behavior analysts from participating in Medicaid because of documented fraud concerns.
{{#rendered}} {{/rendered}}Last month, Republican Florida Gov. Ron DeSantis announced a statewide Medicaid Integrity Initiative to strengthen provider screening, enhance fraud detection and increase oversight aimed at protecting taxpayer dollars.
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While Florida has focused on strengthening fraud enforcement, Georgia lawmakers have focused on reimbursement rates. Lawmakers recently questioned a Medicaid managed care organization's decision to reduce ABA reimbursement rates by 20%, even as industry representatives testified that use of autism therapy services had increased by more than 300% in recent years.
{{#rendered}} {{/rendered}}The debate reflects the difficult balance between rooting out fraud and preserving access to a therapy that many families say has been life-changing for children with autism.