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

Announced on

01/24/2022

| Last Modified on

02/25/2026

| Series Number: SRS-A-25-029

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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 7 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (3)

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

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

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

COMPLETED PROJECTS IN THIS SERIES (4)

Colorado

Project A-09-24-02004 • Completed on February 25, 2026

Audit of Maine's Fee-for-Service Medicaid Payments for Rehabilitative and Community Support Services for Children Diagnosed with Autism

Project A-01-24-00006 • Completed on January 16, 2026

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

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

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 Audit of Indiana's Fee-for-Service Medicaid Payments for Applied Behavior Analysis for Children Diagnosed with Autism - 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 Colorado - 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 Audit of Maine's Fee-for-Service Medicaid Payments for Rehabilitative and Community Support Services for Children Diagnosed with Autism - A-01-24-00006
• November 12, 2024 Project Announced Project OAS-25-02-019
• December 16, 2024 Project Complete - A-09-22-02002 Audit of Indiana's Fee-for-Service Medicaid Payments for Applied Behavior Analysis for Children Diagnosed with Autism has been marked as complete. This audit resulted in 5 recommendations.
• 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.
• January 16, 2026 Project Complete - A-01-24-00006 Audit of Maine's Fee-for-Service Medicaid Payments for Rehabilitative and Community Support Services for Children Diagnosed with Autism has been marked as complete. This audit resulted in 4 recommendations.
• February 25, 2026 Project Complete - A-09-24-02004 Colorado complete. Report Published
• Today 3 Projects In-Progress
• Est FY2026 Estimated Fiscal Year for Series Completion

4 REPORT PUBLISHED

#### 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 (A-01-24-00006) 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).

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 #### 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.

Recommendation Details (6)

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) Indiana’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.

Recommendation Details (5)

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 #### Colorado Made at Least $77.8 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children (A-09-24-02004) Colorado’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.

Recommendations are updated each month and may not immediately be available for recently completed projects. 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