ABAI Statement Regarding ABA Services and Medicaid Improper Billing Allegations
As the international organization for the science of behavior, or behavior analysis, the Association for Behavior Analysis International (ABAI) addresses recent media coverage of Medicaid improper billing allegations involving applied behavior analysis (ABA) services for autistic persons in the United States.
As often occurs, increased funding availability for a service or product is accompanied by increased risk of unscrupulous persons seeking to exploit those resources. That possibility has emerged in connection with Medicaid funding of ABA services. In recent months, multiple reports published by the Office of the Inspector General (OIG) of the United States have identified improper and potentially improper Medicaid billing for ABA services for autistic individuals, predominantly children. Recent articles in The Wall Street Journal and elsewhere have highlighted these findings, suggesting possible fraudulent billing.
ABAI unequivocally condemns illegal activities of any sort by anyone, including improper or fraudulent billing for ABA services. The limited public resources available to provide medically necessary ABA must not be misused or exploited. Behavior analysts are expected to comply fully with all applicable laws, regulations, professional and ethical standards, and contractual obligations. Following due process, individuals found to have engaged in fraudulent activities should be subject to the consequences prescribed by laws, professional standards, and relevant contracts.
A careful review of the OIG reports indicates that ABAI must do more to promote clear and consistent understanding of evidence-based ABA, the proper use of the Current Procedural Technology billing codes commonly used to bill for medically necessary ABA, and the clinical documentation required to support billable services. A significant portion of the questionable billing identified by OIG involved insufficient clinical documentation and activities that are not typically billable. Although evidence-based behavior analysis produces substantial data, some behavior analysts and the technicians they supervise require additional training to ensure that documentation reflects the purpose, duration, and medical necessity of services provided.
ABAI’s ABA Billing Codes Commission has met with OIG auditors and values the collaborative dialogue that characterized our discussion. We share OIG’s commitment to safeguarding Medicaid funds and appreciate the auditors’ recognition of the clinical and operational nuances inherent in ABA. Ongoing engagement between OIG and the field of behavior analysis is essential to promoting program integrity while preserving access to medically necessary, evidence-based ABA.
As regulators and behavior analysts respond to the concerns raised by the OIG audits, we cannot lose sight of the substantial and well-documented benefits of ABA for thousands of autistic individuals. Efforts to combat waste and abuse must preserve access to high-quality ABA that reflects best practices. A robust body of research demonstrates the effectiveness of ABA in promoting socially meaningful, individualized, and ethically informed behavior change across the lifespan. Such services are derived from taking a natural science approach to the study of behavior. Numerous rigorous research reviews have established that ABA services provided for autistic individuals can be life-changing in assisting them in developing daily living, social, communication, self-management, and academic skills that result in their experiencing greatly increased quality of life. Multiple research reports and literature reviews indicate that for many autistic persons, such gains are most likely when they receive about 40 hours a week of intensive ABA services. For others, similarly important gains occur with fewer hours of intensive but consistent, evidence-based ABA services. Decisions about the amount of ABA services a person needs are determined individually based on the person’s strengths, challenges, and desires.
ABA services should be provided by, or under the supervision of, individuals who are highly trained, experienced, and credentialed in behavior analysis. These professionals supervise specially trained technicians or assistants, similar to supervision models used in other health professions, such as speech-language pathology and physical therapists.
Effective ABA requires individualized assessment, data-driven service planning based on principles and procedures drawn from basic behavioral research, accurate and consistent implementation, data collection, frequent review, and, as needed, service revision.
The effectiveness of ABA in improving the quality of life for autistic individuals is reflected in its endorsement by numerous respected and prestigious governmental and professional organizations (e.g., U.S. Surgeon General, New York American Academy of Pediatrics, Autism Society of America, Council of Autism Service Providers, Centers for Medicare and Medicaid). ABA is widely recognized as the gold standard for addressing the developmental delays and interfering behaviors associated with autism. ABAI strongly endorses humane, socially meaningful, individualized, and ethical ABA. All ABA services are expected to comply with all applicable laws, regulations, and professional and ethical standards.
ABAI notes that the vast majority of behavior analysts comply with applicable laws, regulations, professional standards, and contracts and do not engage in improper billing activities. One behavior analyst improperly billing is too many, but the number of behavior analysts accused of improper billing is a very small percentage of the behavior analysts providing ABA services in the United States. The vast majority are providing ethical, effective services that improve quality of life for autistic individuals and their families. Efforts to address improper practices must not undermine the hard-won access to medically necessary ABA services.