U.S. Health agency plans audit of payments for autism services

Did state Medicaid payments conform to guidelines?

In June of 2021, the United States Department of Health and Human services, through its Office of Inspector General, announced that it plans to audit claims for Medicaid support of applied behavior analysis services to children with autism and their families. In an announcement posted under the title, "Audit of Medicaid Applied Behavior Analysis for Children Diagnosed With Autism," the OIG for HHS identified two areas of concern: "questionable billing patterns by some providers" and "payments to providers for unallowable services."

An audit is an investigation of an organization or process for accomplishing some outcome. In this case, the OIG appears to be concerned about irregularities in providers' billing for ABA services.

There is no indication that individual parents and children are going to be investigated. Apparently, the questions have to do with ABA service providers and whether they have submitted fraudulent claims for reimbursement. ABA providers should be safe from investigation as long as they are “doing things by the books.”

The results of the HHS OIG's audit are slated to be available in 2022. In 2020, according to its Report to Congress, HHS OIG produced 178 reports. None of them referred to autism or applied behavior analysis.

That is not to say that there hasn't been some controversy about reimbursements for ABA services for individuals with autism.

  1. In April 2021, the U.S. Attorney's Office for Connecticut announced that the owner of a company that provide ABA services for children with autism pleaded guilty to a charge of billing for services that never were delivered. In a press release, the U.S. Department of Justice reported that acting US Attorney Leonard C. Boyle announced that the owner and operator of an ABA provider called Helping Hands Academy, "NICOLE M. BALKAS, 31, of Bridgeport, waived her right to be indicted and pleaded guilty...to one count of health care fraud" (emphasis in original). According to the press release, the cost to Medicaid of the fraudulent billing was a loss of $551,311.85.

  2. In a separate release from June 2021, Justice reported Mr. Boyle announced that an employee of Helping Hands Academy, Jessica Stuart, also waived her right to be indicted and pleaded guilty to providing services that she was not authorized to provide. Helping Hands Academy billed Medicaid for services that were supposed to be delivered by a Board Certified Behavior Analyst, although Ms. Stuart has no college degree, let alone board certification as a BCBA. Medicaid's loss was $369,439.96.

  3. In 2018, there were whistleblower accusations (see Brian Mahany's "Autism, Medicare Fraud & Applied Behavioral Analysis") about services for children with autism provided by a company that is probably the largest U.S. provider of ABA services for autism, Centria Healthcare. Importantly, in 2019, according Elisha Anderson of the Detroit (MI, US) Free Press, Michigan authorities closed the investigation without bringing any charges for criminal wrongdoing. However, authorities filed charges against an ABA therapist for billing for services that she did not actually provide. To learn more about the issues surrounding Centria Health, see the table of contents from the Free Press about its extensive investigation.

  4. In 2018, according to Daniel Chang of the Miami Herald, Florida officials investigated fraudulent billing of Medicaid for ABA services for students with autism. In his story, "Autistic kids could lose care as Florida cracks down on Medicaid fraud," Mr. Chang reported that the State of Florida's Agency for Health Care Administration had taken action against four Florida-based ABA providers (DRA Behavioral Health; Harmony Mental Health and Behavioral Services; Meli Medical Center; and MGM Case Management Services, doing business as MGM Behavioral) for fraud that amounted to at least $1,000,000. His story includes links to the Florida AHCA documents, if a reader would like to read the details. Readers interested in determining whether a Florida ABA services provider has been sanctioned for problems (not just fraud) can search the AHCA data base by the provider's name or the company name.

These Connecticut, Michigan, and Florida cases look to me to be examples that likely contributed to the opening of the HHS OIG audit. If the OIG has multiple cases of providers falsely billing for millions of dollars for services that either were not provided or were provided by personnel who did not have requisite training, it should be unsurprising that there will be an audit to determine how extensive the problem is.

In a twist that is intriguing to me—and I am not an expert in these matters, so it may be common—the announcement includes language that sounds supportive of ABA services for children with autism. Here is the full text of the announcement:

Autism spectrum disorder (autism) is a developmental disability that can cause significant social, communication, and behavioral challenges for children. According to the Centers for Disease Control and Prevention, there is currently no cure for autism; however, research has shown that early intervention and treatment can improve a child's development. A common treatment for autism is Applied Behavior Analysis (ABA). ABA can help an autistic child improve social interaction, learn new skills, maintain positive behaviors, and minimize negative behaviors. In the past few years, some Federal and State agencies have identified questionable billing patterns by some ABA providers as well as Federal and State payments to providers for unallowable services. We will audit Medicaid claims for ABA services provided to children diagnosed with autism to determine whether a State Medicaid agency's ABA payments complied with Federal and State requirements.


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