Applied Behavior Center for Autism: Skill-Level Upcoding, Groups and Duplicate Payers

In the Applied Behavior Center for Autism fraud case, the Justice Department recovered $2 million in a civil settlement over alleged ABA upcoding and false billing to TRICARE and Indiana Medicaid. The alleged false claims took money intended for the care of military and Medicaid families. A technician, analyst or billing employee could recognize different parts of that story: whose work appeared on a claim, how a group became individual treatment on paper, or why a paid service was billed again.

The February 10, 2023 announcement named ABA Programming Inc., known as Applied Behavior Center for Autism, and its owner, the provider’s founder and chief executive. Applied Behavior Center provided applied behavior analysis services to people with autism at locations across Indiana. The government alleged several distinct ways that its claims misrepresented the services or the payments behind them.

What the Claims Said About the Care

The government’s allegations concerned the skill level billed, concurrent and duplicate claims, group therapy and undisclosed payments from other insurers. Each points to a different part of the operation, from the treatment room to the billing office.

Technician Work Billed at an Analyst Level

The government alleged that Applied Behavior Center upcoded technician services, billing work at an analyst level when a technician had delivered it. The government was paying for a level of work it alleged the provider had not delivered.

That distinction matters in ABA because treatment codes describe different workers and different services. Technician treatment, assessment and a qualified practitioner’s modification of a treatment protocol have separate billing descriptions. In Indiana’s fee-for-service Medicaid system during the period the HHS Office of Inspector General audited, the codes were billed in 15-minute units. Each unit therefore carried both a service description and an amount of treatment time.

For someone who worked on the clinical team, the useful knowledge is concrete: who treated the child and what that person actually did. An analyst service on the bill and a technician assigned to the child put the staffing record and the submitted claim at the center of the inquiry.

Concurrent Claims and Duplicate Claims

Concurrent ABA billing was another part of the case. The government alleged that Applied Behavior Center submitted claims to TRICARE and Medicaid for analyst and technician services rendered concurrently to the same patient on the same date. The settlement also addressed alleged duplicate claims.

For a clinician who knows what happened during that session, the relevant detail is the work behind each claimed service. For a billing employee, it is also whether the service has already appeared on another claim. A calendar can place the workers together. The service notes and billing history explain what the provider charged for their time.

Group ABA Billed as Individual Care

The government alleged that Applied Behavior Center submitted Medicaid claims for group therapy as direct one-on-one treatment. It separately alleged that the provider billed TRICARE for group therapy services that TRICARE did not cover.

A worker who knows which children were treated together has information that a claim labeled individual treatment leaves out. The attendance and session records can connect the actual arrangement to the billing description. In the government’s account, the claim presented a different version of the treatment room.

Medicaid Claims Another Payer Had Already Paid

The duplicate-payer allegation went beyond how the treatment was coded. The government alleged that Applied Behavior Center submitted Medicaid claims for services already paid by TRICARE or the Indiana CareSource marketplace, without telling Medicaid about those payments.

Here, the payment history is central. The alleged omission concerned money already received for the service now presented to Medicaid. A billing employee working with claims and payer remittances may see the earlier payment and the later submission together, while a treating technician sees only the session.

WTF Is Billable?

Billable ABA depends on the service, the worker, the time and the payer’s rules. The distinctions behind the Applied Behavior Center allegations appear in the billing codes: 97153 describes technician individual treatment, 97154 technician group treatment, and 97155 qualified-practitioner treatment with protocol modification. They distinguish individual care, group care and changes to a treatment protocol within the same practice.

In the inspector general’s separate December 2024 Indiana audit, auditors examined fee-for-service Medicaid payments for 2019 and 2020. They found claims billed for protocol modification whose session notes did not support a modification. Some notes expressly recorded that no changes had been made. The service described by the code and the service described by the clinician were at odds.

The Settlement and the Estimated Losses

The government’s estimated losses were $348,194 to Medicaid and $626,795 to TRICARE. The settlement recovered more because it included double damages and some of the government’s investigative costs. Applied Behavior Center agreed to pay the United States and Indiana together, yet still denied liability.

The Justice Department described the resolution, when announced, as the largest TRICARE settlement collected in the Southern District of Indiana.

The Department of Defense Office of Inspector General, the Department of Health and Human Services Office of Inspector General, the Indiana Attorney General’s Medicaid Fraud Control Unit and the FBI worked on the investigation in coordination with the U.S. Attorney’s Office. Their work connected the claims submitted to both government health care programs.

ABA Fraud? Has Anyone Experienced This?

Other ABA providers have settled allegations involving the same kinds of billing discrepancies. The Autism Concepts settlement addressed allegations that TRICARE claims represented individual treatment while children received simultaneous group services. It is the same service-format mismatch that a worker can recognize from the way a session ran.

The Early Autism Project settlement addressed a different mismatch. The government alleged that therapy hours were reserved for regional administrative positions despite those employees doing no work with the child being billed. It also alleged padded ABA time submitted to TRICARE and South Carolina Medicaid. A former employee brought that whistleblower case.

In a separate Connex Family Services complaint, a former employee alleged that bills to a Medicaid managed-care plan mixed duplicate services with services never performed:

The complaint went on to allege that the plan failed to recognize the unperformed services on the remaining dates. Removing duplicate charges could leave another false claim standing. That is what the whistleblower’s account adds: the person familiar with the services could explain more than the repeated dates on a bill.

Billing Fraud, Unreasonable Expectations, or Both?

Billing expectations become a fraud concern when staff are expected to claim work they did not deliver. Applied Behavior Center’s settlement addressed alleged differences between the care billed and the care provided, including the worker’s skill level and whether treatment was individual or in a group. The useful account from inside a provider connects what staff were expected to bill with what they actually did.

Authorization, attendance and delivery answer different questions. An authorization approves treatment. The session record describes what followed. In its Indiana review, the inspector general examined authorizations, treatment plans and session notes separately, including whether the notes supported the units paid. That separation gives substance to a concern about billing expectations: the approved hours, the delivered work and the submitted claim can be compared.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know the Session Behind the Claim

If your work at an ABA provider exposed a gap between the treatment delivered and the claims submitted, speak to our whistleblower experts about the sessions behind those claims. We work with you to build your strongest ABA billing whistleblower case and bring in healthcare fraud whistleblower lawyers who understand the workers, sessions and payments behind it. We stay beside you throughout the case.