OIG audits flag hundreds of millions in improper autism therapy payments. Dr. Gina Green says providers and regulators share the blame, and the fix is partnership.
A wave of federal audits has put Medicaid billing for ABA services for beneficiaries with autism under a microscope. Office of Inspector General reviews are part of a seven-state series begun in 2022, and the four reports released so far tell a consistent story.
In Indiana, the OIG found at least $56 million in improper fee-for-service Medicaid payments for ABA, plus another $76.7 million it judged potentially improper. Wisconsin drew findings of at least $18.5 million improper and an estimated $94.3 million more potentially improper. Colorado’s were the largest: at least $77.8 million improper and a further $207.4 million potentially improper, roughly $285 million in all. Maine, whose audit examined the broader category of rehabilitative and community support services for individuals with autism rather than ABA alone, was found to have made at least $45.6 million in improper payments. Colorado disagreed with one of the OIG’s recommendations and agreed or partially agreed with the rest. At the state level, Massachusetts has pursued its own multimillion-dollar recoupment from ABA providers. The common threads are thin documentation, uncredentialed staff, and billing that does not match the record.
CalABA, the California Association for Behavior Analysis, issued a public statement responding to media coverage and the OIG reports. Dr. Gina Green, a past CalABA president and now a public policy consultant to the organization, helped shape that response, and she elaborated on it in an interview with Acuity Media Network. (Her CalABA advocacy role is disclosed here for that reason). “None of us in the field condone any improper billing practices,” she told Acuity. While Green is clear that the field does not defend bad billing, she argues that before regulators subtract, they need to sort.
One Category, Many Treatments
Green’s central point is definitional, and she thinks it is widely misunderstood. When auditors examine “behavioral health treatment” claims, she says, they should not assume the entire category is ABA. “There’s no single behavioral health treatment. There are many treatments,” she said. “Applied behavior analysis is just one subset of this larger category.”
That larger category, she explains, includes various therapies that professionals such as psychologists, counselors, and social workers have long provided, often to people experiencing anxiety, depression, or other conditions once filed under “mental health.” Those professions, Green notes, “have been around for decades, much longer than applied behavior analysis,” and are licensed in every state. “Behavior analysis is kind of the new kid on the block,” she said, and even now ABA practitioners are licensed in only 38 states and the District of Columbia. The practical risk is that a regulator who reads every behavioral health line item on claims as ABA services will draw the wrong conclusions about where problems actually sit.
The service itself compounds the confusion. ABA services are not delivered via the periodic office visits with licensed professionals that many payers built their behavioral health billing systems around. They are delivered where patients live and learn, often for many hours and multiple sessions a week, and are overseen and delivered by clinicians at different credential levels. “Our services are just so different from what health plans are used to,” Green said. That mismatch, she argues, is part of why oversight has been so uneven.
How EPSDT Built a Patchwork
The Medicaid story runs through a benefit called EPSDT (Early and Periodic Screening, Diagnostic and Treatment), which has existed since 1967. It entitles eligible Medicaid beneficiaries under 21 to any medically necessary service when a concern is identified, and, as Green emphasizes, it is not diagnosis specific. On July 7, 2014, the Centers for Medicare and Medicaid Services issued an informational bulletin reminding states of that obligation and clarifying that it could include ABA services for children with autism.
What the bulletin did not do was standardize anything. “There’s been a lot of variability in how each of the state Medicaid programs have responded,” Green said, shaped by each state’s politics, economics, and interpretation. The reimbursement rates for ABA “varied a lot from one state to the next,” as did the definitions of who counts as a qualified provider. Acuity’s weekly state-by-state rate comparisons, produced with MediRate, show the same picture in granular detail: even widely used CPT billing codes such as 97153 and 97155 carry very different rates depending on state, provider level, and place of service.
Layered on top is a churn problem that makes consistent compliance hard. Many commercial health plans, Medicaid programs, and TRICARE (the military’s health program, run by the Department of Defense rather than as commercial or Medicaid coverage) each adopt different subsets of billing codes with different definitions and documentation requirements, and those rules keep shifting. A provider may spend months teaching a payer’s staff how ABA works, Green notes, only to have those contacts “leave, get moved up in the payer hierarchy,” or move to another company, at which point “you have new people and you’ve got to start the education process all over again.” The same issues, she says, run through some state agencies that regulate Medicaid.
Who Is Responsible, and What Comes Next
One detail in the OIG reports stands out to Green: the auditors did not aim only at providers. They “faulted the state agencies that are administering these Medicaid programs for not providing sufficient oversight, for not communicating to providers what the expectations are with regard to billing and documentation,” she said, and some state programs have acknowledged as much.
She is equally clear that this does not excuse providers. “I’m not letting the providers off the hook at all here,” she said. “If you’re a provider, you are responsible for making sure you follow the laws and regulations and professional standards.” The tension is one Acuity has heard from providers elsewhere: in Massachusetts, clinicians facing recoupment demands described the experience as driving down a highway with no posted speed limit and then receiving a ticket, a complaint about unclear rules rather than a denial of responsibility.
Green’s prescription is partnership rather than blame. “The best approach for behavior analysts and the behavior analysis state associations is to try to partner with the state Medicaid agencies,” she said, “saying, let’s work together to try to figure this out.” State agencies, she adds, are stretched thin and still learning how ABA differs from other services, a strain visible in payer actions from Georgia’s recent CareSource rate cut to Indiana’s reimbursement overhaul.
The timing worries her most. The One Big Beautiful Bill Act, signed in July 2025, cuts roughly $1 trillion in federal Medicaid funding over a decade, by Congressional Budget Office estimates, with the reductions, new work requirements, and more frequent eligibility checks phasing in across 2026 and 2027. “It’s going to be devastating all over the country for people with autism and other developmental disabilities when the Medicaid cuts really kick in next year,” Green said. An oversight reckoning and a funding contraction are arriving at the same moment, which is why she keeps returning to the same message: sort carefully, fix the rules together, and do not mistake a confused system for a fraudulent one, or a fraudulent actor for the whole field.
