Maine Medicaid Autism Services Improper Payments

HHS OIG Reports & Publications

Filed January 16th, 2026

Detected February 11th, 2026

Summary

The HHS OIG has issued a report finding that Maine made at least $45.6 million in improper fee-for-service Medicaid payments for autism services provided to children. The audit identified that all sampled claims were improper or potentially improper, leading to recommendations for refunds and improved provider guidance.

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What changed

The US Department of Health and Human Services Office of Inspector General (HHS OIG) has released a report (A-01-24-00006) detailing that Maine made at least $45.6 million in improper fee-for-service Medicaid payments for rehabilitative and community support services for children diagnosed with autism in 2023. The audit examined 100 sampled enrollee-months and found that all included improper or potentially improper claim lines, estimating the total improper payments at $45.6 million, with a Federal share of $28.7 million.

This finding necessitates that Maine's Department of Health and Human Services refund $28.7 million to the Federal Government and address potentially improper payments totaling an additional $14.1 million. The OIG also recommended that Maine provide enhanced guidance to providers on documenting services and conduct periodic postpayment reviews. Maine has concurred with these recommendations, with updates expected by July 15, 2026, indicating a need for immediate review of internal controls and provider documentation practices related to these services.

What to do next

Review internal controls for Medicaid fee-for-service payments for autism services.
Ensure provider documentation for rehabilitative and community support services meets Federal and State requirements.
Prepare for potential refund of improper payments to the Federal Government.

Penalties

Refund of $28.7 million (Federal share) to the Federal Government for improper payments.

Source document (simplified)

Maine Made at Least $45.6 Million in Improper Fee-for-Service Medicaid Payments for Rehabilitative and Community Support Services Provided to Children Diagnosed With Autism

Issued on

01/16/2026

| Posted on

01/22/2026

| Report number: A-01-24-00006

Report Materials

Why OIG Did This Audit

Early treatment for autism is important because proper care can reduce children’s difficulties while helping them build on their strengths and learn new skills. In Maine, rehabilitative and community support (RCS) services for children diagnosed with autism include applied behavior analysis and other treatments for autism.
Maine’s fee-for-service (FFS) Medicaid payments for RCS services in 2019 were $52.2 million, and by 2023, these payments had increased to $80.6 million.
This audit examined whether Maine’s FFS Medicaid payments for RCS services for 2023 complied with Federal and State Requirements.

What OIG Found

Maine’s payments for RCS services did not fully comply with Federal and State requirements. All 100 sampled enrollee-months included payments for one or more claim lines that were improper or potentially improper. On the basis of our sample results, we estimated the State agency made improper payments of at least $45.6 million ($28.7 million Federal share).

What OIG Recommends

We made four recommendations, including that Maine refund $28.7 million to the Federal Government, provide additional guidance to RCS providers for documenting RCS services, and periodically perform a statewide postpayment review of Medicaid payments for RCS services to educate providers on requirements.

Maine potentially concurred with our first recommendation and concurred with our remaining recommendations. Maine detailed steps it plans to take to address our recommendations.

Recommendation Details (4)

26-A-01-033.01 to CMS - Open Unimplemented Update expected on
07/15/2026 We recommend that the Maine Department of Health and Human Services refund $28,796,366 (Federal share) to the Federal Government for Fee-for-Serivce Medicaid payments for rehabilitative and community support services that did not comply with Federal and State requirements.
26-A-01-033.02 to CMS - Open Unimplemented Update expected on
07/15/2026 We recommended that the Maine Department of Health and Human Services exercise reasonable diligence to review and determine whether any of the estimated ($14,163,521 Federal share) in potentially improper payments for RCS services did not comply Maine's FFS Medicaid Payments for Rehabilitative and Community Support Services with Federal and State requirements and refund the Federal share of any improper payment amount to the Federal Government.
26-A-01-033.03 to CMS - Open Unimplemented Update expected on
07/15/2026 We recommend that the Maine Department of Health and Human Services provide additional guidance to providers about how to document RCS services, including the information needed in session notes to support RCS services provided, billable RCS service time, and signature requirements.
26-A-01-033.04 to CMS - Open Unimplemented Update expected on
07/15/2026 We recommend that the Maine Department of Health and Human Services periodically conduct a statewide postpayment review of Medicaid payments for RCS services, including reviewing medical records, and provide additional training in the areas in which errors were identified by postpayment reviews.
View in Recommendation Tracker Report Type Audit HHS Agencies Centers for Medicare and Medicaid Services Issue Areas Financial Stewardship Non-institutional care Target Groups Children and Families Financial Groups Medicaid