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Series: Audits of Medicaid Applied Behavior Analysis for Children Diagnosed With Autism

Announced on  | Last Modified on  | Series Number: SRS-A-25-029
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

Autism can cause significant social, communication, and behavioral challenges for children. According to the Centers for Disease Control and Prevention, research has shown that early intervention and therapy can improve social and behavioral development in children diagnosed with autism. A common therapy for autism is Applied Behavior Analysis (ABA). ABA can help an autistic child improve social interaction, learn new skills, maintain positive behaviors, and minimize negative behaviors. In the past few years, some Federal and State agencies have identified questionable billing patterns by some ABA providers as well as Federal and State payments to providers for unallowable services. We will audit Medicaid claims for ABA services provided to children diagnosed with autism to determine whether a State Medicaid agency's ABA payments complied with Federal and State requirements.

There are 8 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (5)

Project A-09-24-02004 • Announced on Jul 26, 2023

Project A-05-24-00005 • Announced on Dec 4, 2023

Project A-03-24-00205 • Announced on Feb 7, 2024

Project A-01-24-00006 • Announced on Aug 27, 2024

Project OAS-25-02-019 • Announced on Nov 12, 2024

CANCELED PROJECTS IN THIS SERIES (1)

Audit of Missouri’s FFS Medicaid payments for Applied Behavior Analysis (ABA) therapy for children diagnosed with autism

Project A-07-24-04139 • Canceled on Feb 21, 2025

COMPLETED PROJECTS IN THIS SERIES (2)

Audit of Wisconsin's Fee-for-Service Medicaid Payments for Applied Behavior Analysis for Children Diagnosed with Autism

Project A-06-23-01002 • Completed on July 10, 2025

Indiana

Project A-09-22-02002 • Completed on December 16, 2024

TIMELINE

  • January 24, 2022
    Series Number SRS-A-25-029 Assigned
  • January 24, 2022
    Project Announced

    Indiana - A-09-22-02002

  • April 3, 2023
    Project Announced

    Audit of Wisconsin's Fee-for-Service Medicaid Payments for Applied Behavior Analysis for Children Diagnosed with Autism - A-06-23-01002

  • July 26, 2023
    Project Announced

    Project A-09-24-02004

  • December 4, 2023
    Project Announced

    Project A-05-24-00005

  • February 7, 2024
    Project Announced

    Project A-03-24-00205

  • August 27, 2024
    Project Announced

    Project A-01-24-00006

  • September 6, 2024
    Project Announced

    Audit of Missouri’s FFS Medicaid payments for Applied Behavior Analysis (ABA) therapy for children diagnosed with autism - A-07-24-04139

  • November 12, 2024
    Project Announced

    Project OAS-25-02-019

  • December 16, 2024
    Project Complete - A-09-22-02002

    Indiana has been marked as complete. This audit resulted in 5 recommendations.

  • February 21, 2025
    Project Canceled - A-07-24-04139

    Audit of Missouri’s FFS Medicaid payments for Applied Behavior Analysis (ABA) therapy for children diagnosed with autism

  • July 10, 2025
    Project Complete - A-06-23-01002

    Audit of Wisconsin's Fee-for-Service Medicaid Payments for Applied Behavior Analysis for Children Diagnosed with Autism has been marked as complete. This audit resulted in 6 recommendations.

  • Today
    5 Audits In-Progress
  • Est FY2026
    Estimated Fiscal Year for Series Completion

2 REPORT PUBLISHED

Wisconsin Made at Least $18.5 Million in Improper Fee-For-Service Medicaid Payments for Applied Behavior Analysis Provided to Children Diagnosed With Autism (A-06-23-01002)

Wisconsin’s payments for ABA did not fully comply with Federal and State requirements. All 100 sampled enrollee-months included payments for 1 or more claim lines that were improper or potentially improper.

25-A-06-079.01 to CMS - Open Unimplemented
Update expected on 03/29/2026
We recommend that the Wisconsin Department of Health Services refund $12,287,252 (Federal share) to the Federal Government for FFS Medicaid ABA payments that did not comply with Federal and State requirements.

25-A-06-079.02 to CMS - Open Unimplemented
Update expected on 03/29/2026
We recommend that the Wisconsin Department of Health Services exercise reasonable diligence to review and determine whether any of the estimated $62,334,835 (Federal share) in potentially improper ABA payments complied with Federal and State requirements and refund the Federal share of any improper payment amount to the Federal Government

25-A-06-079.03 to CMS - Open Unimplemented
Update expected on 03/29/2026
We recommend that the Wisconsin Department of Health Services update guidance for CPT code 97155 to require documentation on how issues were resolved or what changes were made to the treatment protocol or POC.

25-A-06-079.04 to CMS - Open Unimplemented
Update expected on 03/29/2026
We recommend that the Wisconsin Department of Health Services provide additional guidance to ABA facilities about how to document ABA, including the information needed in session notes to support ABA provided and billable ABA time, and State signature requirements.

25-A-06-079.05 to CMS - Open Unimplemented
Update expected on 03/29/2026
We recommend that the Wisconsin Department of Health Services develop a procedure to verify the provider who rendered the 97153-focused treatment service and pay the claim based on the rendering provider's specialty level.

25-A-06-079.06 to CMS - Open Unimplemented
Update expected on 03/29/2026
We recommend that the Wisconsin Department of Health Services periodically conduct a statewide postpayment review of Medicaid ABA payments, including reviewing session notes, and provide training in areas where errors were identified by postpayment reviews.

View in Recommendation Tracker

Indiana Made at Least $56 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children Diagnosed With Autism (A-09-22-02002)

25-A-09-026.01 to CMS - Open Unimplemented
Update expected on 04/08/2026
We recommend that the Indiana Family and Social Services Administration refund $39,432,556 (Federal share) to the Federal Government for FFS Medicaid ABA payments that did not comply with Federal and State requirements.

25-A-09-026.02 to CMS - Open Unimplemented
Update expected on 04/08/2026
We recommend that the Indiana Family and Social Services Administration provide additional guidance to ABA facilities for documenting ABA, including services that must be provided to support the use of CPT codes 97155 and 97156, State signature requirements, the detail in session notes needed to support ABA provided, and what the State agency considers billable ABA time.

25-A-09-026.03 to CMS - Closed Implemented
Closed on 03/26/2025
We recommend that the Indiana Family and Social Services Administration periodically perform a statewide postpayment review of Medicaid ABA payments, including reviewing medical records, to educate providers on requirements and to recover payments that did not comply with Federal and State requirements.

25-A-09-026.04 to CMS - Closed Implemented
Closed on 03/26/2025
We recommend that the Indiana Family and Social Services Administration periodically review its prior authorization contractor's procedures for verifying ABA facilities' compliance with requirements for State diagnostic evaluations and treatment referrals for ABA.

25-A-09-026.05 to CMS - Open Unimplemented
Update expected on 04/08/2026
We recommend that the Indiana Family and Social Services Administration exercise reasonable diligence to review and determine whether any of the estimated $53,236,026 (Federal share) in potentially improper ABA payments complied with Federal and State requirements and refund the Federal share of any improper payment amount to the Federal Government.

View in Recommendation Tracker
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Financial Stewardship Non-institutional care
Target Groups
Children and Families
Financial Groups
Medicaid