ABA Therapy Fraud: When Authorized Hours Become False Claims

ABA therapy fraud includes knowingly billing for treatment hours that never happened, group sessions claimed as one-on-one care and technician work billed at an analyst’s level. An authorization approves care for coverage. It does not establish that the child received it. If you deliver the sessions, supervise the staff, submit the claims or bring your child to treatment, you may see the gap between the hours approved and the work the government paid for.

What an ABA Claim Has to Represent

An applied behavior analysis claim represents particular work, for a particular child, by a particular worker. The payer, service date, treatment plan, code and staff qualifications determine what that claim buys. The business submitting the bill and the professional delivering treatment can be different.

In the Indiana program described in the HHS Office of Inspector General’s audit, board certified behavior analysts could enroll as Medicaid providers, while facilities also employed assistant analysts and registered behavior technicians. Both assistant analysts and technicians had to work under supervision. The authorization request needed a diagnostic evaluation, referral and individual treatment plan. After authorization came the treatment itself and the session notes supporting the units billed.

The CMS autism coverage bulletin describes several ways states can cover treatment.

The codes make the distinctions concrete. Technician treatment, group treatment, protocol modification and caregiver guidance describe different work. Indiana’s providers billed these services in 15-minute units. Colorado paid a flat rate per encounter for an initial assessment. Authorization, modifiers and overlapping-service rules also depend on the payer. A code can put a price on a session. It cannot supply the missing session.

In Wisconsin’s audit, technician work paid less than a licensed supervisor’s work under one modifier; under another, the worker’s type did not change the rate. A biller can see how the modifier prices the worker’s time, so we examine the staff assignment and the submitted claim together.

Where the Four State Audits Found the Gap

Federal auditors found recurring problems with session notes, staff credentials and the work behind paid claims in Indiana, Wisconsin, Maine and Colorado.

Indiana’s fee-for-service ABA payments rose from $14.4 million in 2017 to $101.8 million in 2020. In its review of services in 2019 and 2020, the Inspector General estimated at least $56,577,188 in improper payments. It found unsupported codes and units, staff without appropriate credentials, and missing required diagnostic evaluations or referrals.

Wisconsin’s review of 2021 and 2022 estimated at least $18,547,493 in improper payments. The audit identified missing dates and signatures, incomplete descriptions of treatment, possible nontherapy time and incorrect rendering providers. Since the program began in 2016, the state had not performed a statewide postpayment review of ABA documentation.

Authorization at the front door had gone years without that statewide check on what providers actually billed afterward. The missing question is strikingly basic: what did the children receive?

Maine’s review of 2023 covered rehabilitative and community support services for children diagnosed with autism. It estimated at least $45,638,476 in improper payments, with missing assessments, treatment-plan signatures, session documentation and credential records among the findings.

Colorado’s review of 2022 and 2023 estimated at least $77,877,293 in improper payments. Its findings included unsupported codes, missing credentials and diagnostic documentation, and notes describing possible group activities billed as individual treatment.

Evidence of who knowingly changed hours, applied signatures or selected a false code takes the inquiry inside the business.

The Billing Patterns an Insider Can See

The strongest ABA billing evidence connects the claim to the session, the worker and the decision that produced the bill. The cases and audits show several ways those pieces can come apart.

All Authorized Hours Billed, Less Treatment Delivered

Billing all authorized ABA hours when the treatment was not delivered turns permission into revenue. The Smart Therapy criminal charges described that gap.

For an insider, the important comparison is between the authorization, attendance, actual treatment and paid units. A scheduler may see the shortened visit. A technician may know when treatment stopped. A biller may see the full authorized time submitted anyway. We connect those accounts to the same child and service date.

ABA Technician Work Billed as Behavior Analyst Services

ABA technician work billed as behavior analyst services can misrepresent the skill level the payer purchased. Applied Behavior Center for Autism, known as ABCA, and its owner settled for $2 million in 2023 over allegations involving TRICARE and Indiana Medicaid. The government alleged upcoded technician services, improper concurrent claims, group services and claims already paid by another source.

The worker’s credential, assigned role and actual work belong beside the code. Supervision also has its own substance: who directed the treatment, what they did and whether the claimed service describes it. Indiana auditors found copied notes unreliable for showing both what children received and whether technicians were properly supervised.

Concurrent Billing Under 97153 and 97155

Whether concurrent billing of 97153 and 97155 makes a false claim turns on the payer’s rule and the work performed. The first code describes technician treatment. The second describes qualified-practitioner treatment with protocol modification.

During Indiana’s audited period, the state permitted both codes during the same time when a technician delivered treatment and an analyst worked to modify the protocol. Wisconsin’s audit described a different rule: it prohibited billing those codes concurrently. The same clock overlap therefore calls for a different comparison in each program.

Indiana auditors also found protocol-modification claims whose session notes explicitly said no modification had been made. That contradiction puts the treatment note against the service the bill represented. We would want to know who selected that code and what happened when someone questioned it.

The Indiana audit also examined caregiver-guidance claims. Some session notes described a general conversation between an analyst and a parent without documenting guidance on implementing treatment protocols. For the parent or clinician, the useful account is what the conversation actually covered. For the biller, it is what service the claim represented. That comparison gives an insider something specific to explain when a routine conversation appears in the billing system as a more particular clinical service.

An ABA Group Session Billed One on One

An ABA group session billed one on one changes what the claim says each child received. ABCA’s settlement included allegations that it billed Indiana Medicaid for group therapy as direct individual care, and billed TRICARE for group services the program did not cover.

The pattern also appeared in the Autism Concepts settlement. The company and its director agreed to pay $300,000 in 2019 to resolve allegations that they represented group services as individual treatment for children covered by TRICARE.

Good Shepherd Catholic School paid $354,000 in 2023 to resolve a similar allegation about services delivered at its Oklahoma City school. The government alleged that the school billed TRICARE for group ABA when the program required one-on-one services. A child could be present, receiving services, while the claim still described a different arrangement.

Are Community Outings Billable Hours for an RBT?

The answer depends on the covered treatment delivered during the outing and the payer’s requirements. The treatment purpose, technician’s work and documented time matter together. The place alone does not describe the service.

ABA billing during lunch, recreation or school featured repeatedly in the audits. In Indiana, a technician accompanied a child through the school day, while the provider consistently billed the day as ABA. Notes described recess and meals without documenting the specific ABA provided during those periods, and the treatment plan had no eating goals. Other time included the child following a teacher and classroom aide while the technician reviewed data and consulted with an analyst.

The issue for someone who worked that day is concrete. What intervention did the technician provide during the billed period, and what did the session note say happened? That is the conversation we have with you when an attendance record has become a continuous treatment claim.

ABA Billing for Staff Travel Time to a Child’s Home

ABA billing for staff travel time to a child’s home raises the same question about what occurred during the billed minutes. Wisconsin’s audit identified travel among the potential nontherapy time included in session notes.

We examine how the employer recorded the work and what it represented to the payer.

The Signature and the Child-Specific Note

The note has to describe this child’s treatment, and the signature has to identify the worker who provided it. Indiana auditors found records bearing another child’s name and photocopied notes and signatures. Some photocopies had been date-stamped before the service dates.

Colorado’s audit described a facility where billing staff kept scanned or digital staff signatures and applied the images to session notes before submitting claims. That finding makes the signature process itself relevant. Who entered the clinical details, who reviewed them and who attached the signature can be different people. An analyst or technician may recognize work credited to them that they never performed or approved.

What Medicaid and TRICARE Cases Add

The civil cases connect operational practices to government claims: administrative time charged to a child, services billed twice and sessions allegedly never delivered. They also show why a provider’s billing records and an employee’s account belong in the same inquiry.

Billing Children’s Therapy Hours for Company Administration

The Early Autism Project allegations concerned reserving children’s therapy hours to pay for company administration.

Early Autism Project paid $8,833,615 in 2018 to resolve allegations involving South Carolina Medicaid and TRICARE. The government alleged that therapists had to reserve billable time for Regional Leads and Regional Coordinators who were not actively working with the child whose hours were used. It also alleged padded therapy hours for services never provided.

The alleged ABA billing for administrative regional coordinator hours made company overhead look like child-specific treatment. The civil investigation arose from a former employee’s whistleblower case. The allegation connects a management instruction to the hours billed against individual children. We see the absurdity in charging a child’s therapy allowance for running the company.

TRICARE Autism Duplicate Billing and Another Insurer

TRICARE autism duplicate billing can also involve another insurer’s payment. In ABCA, the government alleged that the company billed Medicaid for claims already paid by TRICARE or the Indiana CareSource marketplace without disclosing the earlier payment. The same settlement addressed duplicate claims as well.

The biller’s view can therefore reach beyond the session note. The original claim, payment record and later submission show which program paid for which service, and what the next payer was told.

Connex and the Dates Hidden Among Duplicate Charges

Connex Family Services and its owner agreed to pay $918,000 in 2023 to resolve allegations of ABA services never provided but billed to Medicaid and TRICARE. The settlement arose from whistleblower lawsuits by former employees.

One employee’s complaint described broad date-range bills sent to a Medicaid health plan:

The complaint further alleged that removing duplicate charges still left dates on which no services had occurred. A duplicate-payment check could catch a repeated bill while missing an invented visit. That is why we connect each claimed date to the work behind it.

The same complaint alleged that a technician asked a child’s mother to sign a blank data sheet before each scheduled appointment. It also described a treatment plan carrying a professional’s name when that professional said he had neither treated nor known the patient. Those allegations connect the parent’s view to the clinician’s: the family may see when a signature was requested, while the professional knows whether the attributed work was theirs. Both can help explain how a completed-looking record reached billing.

When an Autism Parent Kickback Is Tied to Authorized Hours

An autism parent kickback tied to authorized hours can make the approval itself part of the payment arrangement. The criminal information against an individual in the Smart Therapy case, described in the Justice Department’s charging announcement, alleged maximum-hours billing despite incomplete or absent treatment, unqualified technicians and unauthorized supervising-professional signatures. The charging account also alleged parent payments that increased with authorized service amounts.

The Justice Department’s separate account of a criminal information against an individual in the Star Autism Center case described allegations of inflated or undelivered services, unqualified technicians and parent payments.

For an employee or parent who knows about the payments, the connection to authorized hours matters alongside the staffing and treatment records. We can work through those facts with you and identify how they connect to the claims for care.

What an ABA Insider Can Connect

A technician’s account of the session, an analyst’s knowledge of the plan and a biller’s payment history can explain different parts of the same claim. Schedules, staffing and payroll records add who was available to do the work. Notes and signatures show who took responsibility for describing it. Instructions to reserve hours, use a different code or submit already-paid services can connect the discrepancy to a decision inside the company.

We work with that operational knowledge to assess a potential health care fraud case, including the payer’s requirements for the services at issue. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know What Happened During Those Hours

If you know the sessions, staffing or signatures behind an ABA bill, speak with our whistleblower experts about the care the claim describes. We work beside you to build a case from what happened inside the provider and bring in healthcare fraud whistleblower lawyers who understand Medicaid and TRICARE billing. You bring the knowledge of the work; we stay with you as that knowledge becomes the foundation of your case.