The Centers for Medicare and Medicaid Services released a new toolkit to help state Medicaid programs protect children with autism and strengthen oversight of Applied Behavior Analysis therapy services on Aug. 4, addressing a rapidly growing area of documented billing fraud.
ABA therapy for autism has grown into a multibillion-dollar Medicaid service sector with documented problems including billing fraud, inappropriate treatment intensity, and quality inconsistency across providers, according to CMS.
The toolkit provides states with specific tools and guidance to monitor ABA providers, identify fraud indicators, and ensure appropriate treatment duration and intensity for individual children, the agency said.
State Medicaid programs have struggled to maintain oversight of an ABA provider market that expanded rapidly following autism parity legislation and Medicaid coverage mandates. The number of ABA providers has grown dramatically in recent years, outpacing state agencies’ ability to monitor quality and billing compliance.
Children with autism represent a significant share of Medicaid enrollment in pediatric populations, and ABA therapy is one of the most expensive per-beneficiary services in state Medicaid programs, according to CMS.
The toolkit addresses dual concerns: protecting vulnerable children from inappropriate or excessive treatment, and safeguarding the fiscal integrity of Medicaid programs that are already under significant budget pressure in states across the country.
ABA therapy, when appropriately delivered, is considered the gold standard behavioral intervention for children with autism spectrum disorder. However, the rapid commercialization of ABA services has raised concerns about providers prioritizing billing over treatment quality, CMS said.
State Medicaid directors can begin implementing the toolkit guidance immediately in their oversight programs.