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| TO: | Dr. T. March Bell Inspector General Office of Inspector General (OIG) U.S. Department of Health and Human Services (HHS) Washington, DCCC: Dr. Mehmet Oz Administrator Centers for Medicare & Medicaid Services (CMS) U.S. Department of Health and Human Services (HHS)The Honorable Robert F. Kennedy, Jr. Secretary U.S. Department of Health and Human Services (HHS) |
| FROM: | Dr. Henny Kupferstein, Policy Analyst, Doogri Institute |
| DATE: | March 17, 2026 |
| SUBJECT: | Audit Findings: Medicaid Applied Behavior Analysis Billing Patterns in Texas |
| RE: | Request for Federal Scrutiny of Texas Public and Private ABA Service |
The Armadillo Effect: How Managed Care Shields Texas Medicaid Autism Billing from Public and Federal Scrutiny
CMS Audit: March 17, 2026
This audit evaluates selected Applied Behavior Analysis (ABA) services delivered under Texas Medicaid, with a focus on billing practices, service delivery structures, and patient experience indicators. The findings are hereby formally submitted to the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) for federal review. We are requesting that Texas be federally scrutinized under the HHS-OIG Work Plan SRS-A-25-029 audit project.
Texas operates one of the largest Medicaid programs in the United States. Recent federal enrollment data place California first, New York second, and Texas third in Medicaid and Children’s Health Insurance Program (CHIP) enrollment, with approximately 4.1 million beneficiaries enrolled in Texas as of late 2025. Because of the scale of the program, even relatively small levels of improper billing can expose federal and state governments to substantial financial losses.
This report presents findings from a systematic analysis of publicly available federal datasets examining billing patterns associated with Applied Behavior Analysis (ABA) services provided to Medicaid beneficiaries and linked to providers registered in the State of Texas. The analysis integrates information from the CMS National Plan and Provider Enumeration System (NPPES) National Provider Identifier Registry and the U.S. Department of Health and Human Services Medicaid Provider Utilization and Spending dataset (CY2018–CY2024).
The analysis reviewed 24,554 behavior technician and behavior analyst NPIs registered in Texas and examined associated Medicaid billing activity conducted through their affiliated billing entities. Screening procedures were designed to identify utilization patterns inconsistent with the operational realities of ABA service delivery or with regulatory supervision requirements governing behavior technicians.
Across the datasets examined, multiple billing entities and rendering providers displayed patterns that may be indicative of fraudulent or improper billing, including:
- Claims reflecting service volumes exceeding physically possible daily working hours
- High concentrations of technician-delivered services with minimal or absent supervisory billing by licensed behavior analysts
- Billing networks sharing addresses, phone numbers, or rendering providers across nominally independent entities
- Templated or uniform billing patterns inconsistent with individualized treatment plans
- Rapid activation and deactivation of rendering providers associated with high billing volumes
In total, $201,673,118.81 in Medicaid payments were identified as linked to services rendered by Texas-registered individual providers within the national dataset examined.
These findings are consistent with a broader national pattern identified in recent HHS Office of Inspector General audits, which have documented substantial improper payments associated with ABA services in multiple state Medicaid programs. Recent audits have identified:
- Colorado: $77.8 million in improper payments and $207.4 million in potentially improper payments
- Indiana: $56 million in improper payments and $76.7 million in potentially improper payments
- Wisconsin: $18.5 million in improper payments
- Maine: $45.6 million in improper payments
Despite the size of its Medicaid program and its substantial ABA service utilization, Texas has not yet been the subject of a comprehensive federal audit focused specifically on ABA billing practices.
Given the scale of Medicaid expenditures involved and the patterns identified in the data analysis, the findings presented in this report suggest the need for further federal and state investigation to determine whether services billed were actually rendered, whether required supervision occurred, and whether billing practices comply with applicable Medicaid regulations and federal healthcare fraud statutes.
Request for Federal Scrutiny of Medicaid-Funded
Autism Service Industry in Texas
This complaint presents evidence of suspected Medicaid fraud involving Applied Behavior Analysis (ABA) providers operating in Texas and through Texas-linked multi-state billing networks. Using publicly available federal provider-registration and Medicaid-utilization datasets, the analysis identified patterns consistent with claims for services that were not rendered as billed, technician services lacking adequate supervisory support, rendering activity that exceeded physical possibility, and cross-state billing structures that may conceal responsibility for false claims. The Texas-specific exposure identified in this analysis exceeds $201.7 million in payments tied to Texas-registered individual NPIs, with additional exposure flowing through out-of-state entities using Texas renderers as a major revenue source. A federal investigation is best suited to evaluate whether out-of-state ABA billing entities deriving substantial revenue from Texas-registered rendering providers are using interstate corporate structures, shared infrastructure, or cross-jurisdictional credentialing arrangements to submit false or inflated Medicaid claims.