CASP Responds to Wall Street Journal Articles

This week, The Wall Street Journal published two articles highlighting important compliance issues in applied behavior analysis (ABA) Medicaid programs: “The Medicaid Autism Racket” and “The Boom in Autism Therapy is Medicaid’s Largest Jackpot.” But they don’t provide the full picture.

Fraud, waste, and abuse occur in ABA—and it has to stop. The U.S. Department of Health and Human Services Office of the Inspector General (HHS OIG) found major compliance issues in its state audits, including improper and potentially improper payments. They found bad actors who should be removed from the industry. And they identified providers who must be educated and held accountable for failing to adhere to standards. As the non-profit trade association whose mission is to cultivate, share, and advocate for best practices in autism services, CASP supports HHS OIG’s accountability efforts. In fact, we’ve been engaged with them for months.

What does accountability look like? HHS and the Centers for Medicare and Medicaid Services (CMS) may take the following steps to strengthen program integrity:

• Require a qualifying diagnosis, diagnostic evaluation, or medical documentation indicating medical necessity.
• Require services to be preauthorized as well as a referral or prescription. 
• Add requirements for patients receiving intensive services over a long period (e.g., 30+ hours per week for more than three years).
• Specify clinical documentation standards consistent with CASP’s session note templates.
• Consider additional safeguards like requiring accreditation, aligning behavior technician supervision standards with BACB minimum requirements, and adopting Medicaid Medically Unlikely Edits (MUEs) to catch incidents of unlikely billing.

It’s important to recognize that many compliance issues are simply incorrect documentation of legitimate, preauthorized services. Providers have to do better, but state guidance and oversight must also improve. State Medicaid programs must develop clinical coverage policies with clear provider requirements, beneficiary eligibility standards, medical necessity requirements, documentation standards, and post-payment audit processes. CASP is ready, willing, and able to help states bring clarity and accountability to their autism Medicaid programs.

These issues don’t invalidate ABA as an autism treatment. We have decades of scientific data proving it works. It’s certainly not “glorified daycare.” For children with autism, play and everyday activities are the most effective way to generalize skills like communication, social interaction, and following a schedule. The outcomes are transformative. Autistic children who receive ABA services are more likely to catch up to their peers, live independently as adults, and find employment success.

The correct treatment intensity—especially during the 0-6 developmental period—is critical to achieving those outcomes. Every patient has unique needs, and CASP’s ABA Practice Guidelines do not make a blanket recommendation of 40 hours per week. However, there’s a proven correlation between higher numbers of ABA hours and better outcomes for children with autism. Those who receive 30+ hours of ABA weekly are twice as likely to close cognitive development gaps compared to kids who receive less than 12 hours. They’re also three times more likely to achieve average everyday skills, such as successful communication and participating in homelife.

Children with autism need ABA. Done right, these services help them reach their potential. Every time a provider abuses the system, patients pay the price. We must work together as a community, with HHS OIG, and with states to eliminate fraud, waste, and abuse—ensuring people with autism have access to quality, ethical care.