Tag: medicaid

Audit Findings: Medicaid Applied Behavior Analysis Billing Patterns in Texas

Audit Findings: Medicaid Applied Behavior Analysis Billing Patterns in Texas

Doogri Institute

… Continue reading the full PDF of “CMS Audit Request – Texas Pilot – March 17, 2026”.

The HTML version below is missing the graphics and accessible table of contents. Use the PDF link to see the entire fraudit in accessible format. 

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.

… Continue reading the full PDF of “CMS Audit Request – Texas Pilot – March 17, 2026”.

Idaho bans ABA fake autism therapy by removing Medicaid coverage in the State Plan

Idaho bans ABA fake autism therapy by removing Medicaid coverage in the State Plan

Doogri Institute

Idaho has become the first state to explicitly end Medicaid funding for Applied Behavior Analysis (ABA) therapy, closing the door on an era marked by widespread fraud, billing scandals, and unchecked spending in the autism therapy sector. State lawmakers, in collaboration with the Department of Health & Welfare, have taken decisive action that is both fiscally responsible and aligned with the latest best practices in neurodiversity-affirming care. See section 323 of Idaho Admin. Code r. 16.03.26, “Behavioral Intervention and Habilitative Skill Building,” effective July 2025. 

Follow the #banABA hashtag to stay in the loop of our Autistic-led activism. Additional resources are at http://www.banABA.us

Proactive Leadership: Lawmakers Protecting Public Funds

Idaho spending on ABA therapy and related codes soared to tens of millions of dollars per year, far exceeding projections. Rather than waiting for the type of federal audits or fraud investigations that have rocked other states, Idaho’s lawmakers passed Medicaid reform legislation (HB 345), mandating agency accountability and new spending controls. This legislation set the stage for the Department of Health & Welfare to submit a State Plan Amendment (SPA 23-0011), removing ABA therapy and its associated billing codes from the state plan and transitioning to habilitative Behavioral Intervention (BI) through the Children’s Habilitation Intervention Services (CHIS) model. ​

The Transition: From Fraud-Prone ABA to Habilitative Support

For years, Idaho—like most states—recognized ABA as a “medical necessity” benefit for autistic children under Medicaid’s EPSDT provision. ABA’s clinical model, however, was vulnerable to abuse: inflated billing, unqualified providers, “ghost” services, and vague metrics for outcome and necessity. Idaho’s new approach reclassified autism therapy away from private ABA providers to neurodiversity-informed habilitative care administered via schools and local education teams, with oversight by state agencies and direct integration with individualized education programs (IEPs). 

Key aspects of the system shift in Idaho Admin. Code r. 16.03.26.323

  • ABA CPT codes and medical necessity provisions removed from the state plan.
  • Behavioral Intervention (BI) and habilitative skill-building are now the referenced, reimbursable modalities, far less prone to fraud and waste.
  • Administrative control shifted from managed care organizations to state and school-based oversight, effectively closing the door to the old fraud-prone system. 

Before/After Law Language Comparison Chart

Feature Before Amendment (Pre-2025) After Amendment (Post-2025)
Service Modality Intensive Behavioral Intervention, Applied Behavior Analysis (ABA), Behavioral Modification Behavioral Intervention (BI), Habilitative Skill Building (CHIS)
Legal Reference “Behavioral Modification delivered by a licensed ABA provider.” “Behavioral Intervention is a direct intervention… addressing habilitative skill building needs.” ​
Coverage Type Medical/remedial services, ABA as EPSDT benefit Educational/habilitative, BI under EPSDT/CHIS
Provider Type Licensed BCBAs/ABA staff, certified ABA paraprofessionals Qualified BI staff, school district teams, interdisciplinary providers
Billing Codes ABA CPT codes (e.g., 97151, 97153, 97155) BI/habilitative codes, school-based billing, no ABA CPT
Medicaid State Plan Language “ABA therapy covered when medically necessary for autism.” “Behavioral Intervention and Habilitative Skill Building are covered for children exhibiting maladaptive behaviors.” ​
Accountability Outside BACB credentialing, Medicaid managed care review IEP teams, school districts, state oversight

 

Fiscal Responsibility: Savings, Audit Avoidance, and Medicaid Integrity

Idaho’s reforms are projected to save the state $7–10 million annually in Medicaid spending on autism services alone—dollars that can now be redirected to other critical Medicaid beneficiaries, such as adults with disabilities, seniors, and children with complex medical conditions. So far, 7 states have been required to repay their federal match due to medicaid fraud with ABA medicaid claims. By acting before federal intervention was necessary, Idaho’s leaders: 

  • Kept the state in the clear from federal audits or clawbacks of the federal Medicaid match that have cost other states millions.
  • Prevented the cycles of recoupment, legal battles, payment holds, and administrative chaos suffered by states slower to reform. 
  • Set a bold new national standard for protecting public funds, affirming that Medicaid is for essential, evidence-based, and affirming care—not for lining the pockets of the fraudulent or medically unnecessary ABA industry.

The New Model: Accountability and Inclusion

Behavioral services for autistic children in Idaho are now designed around habilitation, inclusion, and truly educational outcomes—not normalization or compliance for its own sake. This model places IEP teams and local school districts at the center of service provision, subject to robust monitoring, more transparent billing, and meaningful, child-centered progress tracking. 

Idaho’s Medicaid reforms close a chapter on ABA excess and scandal and open the door to sustainable public funding, integrity, and inclusion. By proactively amending the state plan, lawmakers have not only protected Idaho’s budget and fellow Medicaid beneficiaries; they have shown the country how to lead. Idaho stands as a beacon for other states: decisive, principled, and future-forward in the fight against Medicaid fraud—while upholding the rights and needs of autistic children. 

—

The #banABA initiative is founded by Dr. Henny Kupferstein, an autistic autism researcher. All activism is Autistic-led, in line with the mission of the Doogri Institute non-profit research and advocacy agenda. Please consider donating to support this cause. We proudly accept donor-advised fund (DAF) grants.