CASP Non-Member Mission Award winner Dr. Missy Olive on AI-generated ABA session notes, Medicaid program integrity, and the documentation gaps auditors may flag.
Key Takeaways
- AI is entering ABA documentation faster than oversight can absorb it. Olive says some tools now generate full session notes from a few menu clicks, producing records that may not reflect what actually happened during sessions, even though federal rules require documentation to be authentic.
- Regulators are signaling tighter program integrity expectations. Olive speculates that CMS may encourage states toward provider accreditation and/or facility licensure, citing escalating enforcement in states like Massachusetts and Indiana. She favors state licensure for behavior analysis, given that only about a dozen states still lack it.
- Federal auditors are already finding the gaps. The Department of Health and Human Services Office of Inspector General (HHS OIG) has flagged potentially unallowable activities and non-therapy time in ABA session notes rather than alleging fraud outright.
- Standards and training point the way forward. Olive ties quality to documented, expert-built standards such as the CASP 3.0 Guidelines, and would like to see behavior analysis fieldwork moved back into universities, with tighter supervision requirements, to make supervision verifiable. She adds that leadership training for new clinic directors is a skill many training programs still miss.
When Dr. Missy Olive heard her name called for a CASP Non-Member Mission Award at this year’s Council of Autism Service Providers conference, she was not ready for it. “I was just like surprised, I even cried,” she told Acuity Media Network. A behavior analyst certified since 2002 who holds a doctorate in educational psychology, Olive has spent years inside the CASP volunteer committees that shape how autism providers document their work, advocate in their states, and now confront artificial intelligence. The recognition, she said, reflected a career organized around a single idea: that quality care depends on standards, and that standards depend on providers showing what they do.
That thread runs from the company she built to the audits she now performs. In 2010, Olive founded Applied Behavioral Strategies, an ABA agency, and sold it in 2020 to Cultivate Behavioral Health. A doctoral-level board-certified behavior analyst (BCBA-D), she is the Executive Director of the Florida Association for Behavior Analysis (FABA). Dr. Olive is also a contracted reviewer for Florida’s Agency for Healthcare Administration through its Medicaid Program Integrity unit. Speaking in her personal capacity rather than on behalf of FABA, she noted that FABA is the first state association to join CASP as an allied member, a step she encouraged after taking the Executive Director role.
CASP Standards, AI Practice Parameters, and the Non-Member Mission Award
Olive’s involvement with CASP dates to 2019, when her company joined. When the business was acquired the next year, she said, she insisted the buyer remain a member. “I feel like I’ve dedicated my whole life to that mission,” she said, describing CASP’s push for ethical, quality practice as ultimately about the children and adults who depend on providers.
Her volunteer record is long. Since joining in 2019, she has attended every CASP Conference except one, leads the CASP Florida State Advocacy Group, and worked on the documentation special interest group that built out session note templates. She led the work groups on ABA in education, later merged into a single effort to define standards for school-based services. And she co-led the group that produced CASP’s practice parameters on artificial intelligence, work she described as completed in under a year, “right on the heels of AI coming out.”
That AI group is still meeting. Its current agenda includes training for registered behavior technicians, role-specific guidance so that a Chief Executive Officer and a board-certified behavior analyst understand their distinct responsibilities, and a planned publication on AI in higher education, where training programs are wrestling with the technology as both an academic integrity challenge and a teaching tool.
Olive was careful to point to where CASP standards came from. The CASP 3.0 guidelines that funders and regulators increasingly treat as the Generally Accepted Standard of Care (GASC) were first published by the Behavior Analyst Certification Board (BACB) in 2012 and 2014. The BACB transferred the guidelines to CASP in 2020, which formed a committee to revise them into a third edition in 2024. People forget that lineage, she said, but the principle holds: documented, expert-built expectations that providers can be measured against.
When AI Writes the ABA Session Note
It was through her auditing work, Olive said, that she first saw AI being used to document therapy sessions. The realization sharpened a concern she returns to often: many practicing analysts are not fully aware of best practice. This could be due, in part, to where they trained or how they were supervised. Nonetheless, new BCBAs are often unprepared for a basic workforce reality in health care. You have to document everything you do. CASP recently ran a webinar built around a simple instruction, she noted: show your work.
The stakes are concrete. If a provider is assigned four hours with a client, Olive said, the session note has to demonstrate what ABA work happened across those four hours. She pointed to the wave of federal scrutiny of the field, including a series of audits by the Department of Health and Human Services Office of Inspector General (HHS OIG). Those reviews stopped short of alleging fraud, instead flagging what they termed potentially unallowable activities and non-therapy time such as meals or naps. Napping is Olive’s own example: a sleeping child is a child care activity, not behavior analysis, so billing should stop, the note should close, and a new note should begin when the session resumes. And if an organization is supervising naps, she argues, it has pivoted from health care to child care. That raises questions providers must answer, she says: is the organization licensed to provide child care, and can a registered behavior technician serve the same child as both a child care provider and an RBT? She points to the BACB Code of Ethics for Behavior Analysts (1.1) and the RBT Ethics Code 2.0 (1.10).
AI-generated notes complicate that picture. Olive drew a distinction between two approaches. In one, a session is video recorded and AI drafts a template from the actual footage before a human verifies it, an approach she attributed to the vendor Spectrum AI. In the other, a clinician selects a date, a client, and a few activities from a menu, and a complete note appears. “Poof, this note appears that is completely written by AI, and may not even be factual,” she said. It might be true that bubbles were blown, she explained, but not for how long, or toward which ABA targets, and federal rules require documentation to be authentic.
A human reviewer in the loop is necessary but not sufficient, she added. The real question is whether what the AI wrote actually happened. Auditors receive session notes in bulk, often hundreds of searchable pages, and they look for patterns. Florida adds a wrinkle: any individual with a disability and a behavioral need may be eligible, but the state focuses intervention on reducing behavior rather than on both behavior reduction and skill acquisition, unlike many other states. The state’s coverage policy ties services to reducing maladaptive behaviors, requires that care follow CASP’s published standards, and excludes child care outright. So, a note that records “no maladaptive behaviors” over and over, Olive said, can signal that the service was not medically necessary in the first place. AI trained on another state’s framing can import the wrong state regulations entirely.
The problem is not only on the provider side. When the OIG presented at CASP, in a talk Olive attended just after receiving her award, the message cut both ways. It was clear, she recalled, that many providers did not know their own state’s policy, and equally clear that some states were not enforcing the policies they developed.
What Medicaid Program Integrity Needs Next
Asked what other states and providers should prioritize, Olive separated Medicaid oversight from university training. On the Medicaid side, she expects continued movement from the Centers for Medicare and Medicaid Services and would like every state to license the practice of behavior analysis, not because national certification is insufficient, but because state regulation gives states more direct control. She anticipates pressure toward provider accreditation and/or facility licensure, pointing to developments in Massachusetts and Indiana, and said states need real auditing systems, which she is not convinced all of them have had. The federal audits give that prediction weight. The HHS OIG found at least $56 million in improper fee-for-service ABA payments in Indiana, part of a widening review that has since reached Wisconsin ($18.5 million) and Colorado ($77.8 million), while a Massachusetts Office of the Inspector General report flagged providers that billed more than 24 hours of service in a single day.
She was blunt about Florida’s existing facility license, which she called terrible and which Medicaid providers are exempt from anyway. It requires a physician as medical director, she noted, though medicine is not what behavior analysis involves, and, by her account, more than two months of payroll held in reserve, a threshold small providers struggle to meet even as private equity backed companies can.
On training, Olive would like the certification board to move fieldwork back into universities, closer to a physician residency model, so that supervision is documented and harder to falsify. She expects accreditation to hold programs to higher standards measured by outcomes rather than employment, which means little in a field with such demand. She cited work by Cody Morris describing how a newly certified analyst can step directly into a clinic director role without ever having practiced as one. Leaders, she argued, need leadership training and experience.
The workforce is getting younger, and Olive worries that looser supervision is part of why. The certification board requires only a year of experience before someone can supervise independently, she noted, which does not guarantee competence. “I think you see some supervision standards changing down the road,” she said, “or at least I hope we will.”
For all the scrutiny she brings to the field’s problems, Olive is not a pessimist about its disruptors. A forthcoming book chapter of hers argues for a balanced view of private equity, which she said brought real benefits alongside real problems, including funding that has helped universities expand training programs. She is most excited about the higher education paper on AI, a question she frames less as a threat than as a test: how to teach the next generation to use the tools without outsourcing their judgment. It is, in the end, the same standard she has spent a career defending: cultivating, sharing, and advocating for provider best practices in autism services, which she believes lead to quality outcomes for individuals and their families.
