Autism Therapy Billing: What Parents Should Know

Takeaways

• Medicaid coverage and rising autism diagnoses have rapidly expanded applied behavior analysis (ABA) therapy. That growth has increased spending and the number of providers in many states.
• Rapid growth and high reimbursement in some states created opportunities for abusive billing. In Indiana, one provider billed Medicaid more than $340,000 per child, prompting a swift state crackdown.
• Families can protect their child by focusing on quality, not billed cost. Look for strong clinical oversight, a written treatment plan with measurable goals, regular progress data, and recognized accreditation.

Over the past decade, diagnoses of autism spectrum disorder (ASD) have climbed sharply. Among 8-year-olds, the rate rose to one in 31 by 2022, compared with one in 150 in 2000. This surge has driven demand for specialized treatment called applied behavior analysis (ABA), a form of therapy designed to teach children with autism communication, daily living, and social skills through structured positive reinforcement.

In 2014, the federal government required all state Medicaid programs to cover autism services for children. By 2022, every state had complied. This unleashed a surge in demand, as well as spending, that states are still struggling to manage. ABA therapy visits increased by nearly 267 percent between 2019 and 2024.

For families navigating this rapidly expanding market, the key takeaway is critical: High billed costs do not automatically mean high-quality care — and understanding how to evaluate a program is essential.

The financial numbers are striking. The number of companies offering this therapy nearly doubled between 2019 and 2023. Payments from state Medicaid programs to autism therapy providers grew from $660 million to $2.2 billion in the same period. In addition, private insurers that administer Medicaid managed-care plans paid hundreds of millions more.

Who’s Delivering the Therapy and at What Cost?

The Wall Street Journal found that in 2023, state Medicaid programs paid an average of $61 an hour for ABA services. These services tend to be provided by registered behavior technicians, who are often workers with a high school diploma earning less than $20 an hour. These technicians are supervised by more highly trained Board Certified Behavior Analysts (BCBAs), typically with master’s degrees.

That gap between what Medicaid pays providers and what providers pay their frontline workers created room for enormous profit and, in some cases, for exploitation.

For years, Indiana reimbursed providers 40 percent of whatever they billed, rather than using standardized rates. Entrepreneurs quickly realized that simply raising the price they listed for services would automatically increase what the state paid them.

The Most Egregious Case: $340,000 Per Child

The Wall Street Journal’s reporting put a name and dollar figure to the problem. One Indiana provider, Piece by Piece Autism Centers, received $29 million from Indiana Medicaid in 2023 to treat 84 patients — more than $340,000 per child. This figure surpasses what Indiana Medicaid typically spends on a year’s worth of treatment for a newly diagnosed lung cancer patient or a year of nursing-home care.

Piece by Piece had raised its listed therapy prices from $200 per hour to $1,600 per hour under the 40 percent reimbursement system, yielding Medicaid payments of $640 per hour for routine therapy.

Nationwide, Indiana was home to nine of the top 10 providers by per-patient spending in 2023. Meanwhile, Nebraska’s spending on ABA therapy grew from $4.6 million in 2020 to $85.6 million by 2024 — an increase of nearly 1,760 percent. North Carolina’s Medicaid payments for autism services are projected to rise 423 percent between 2022 and 2026.

The Crackdown

The Journal’s reporting prompted swift action. In March 2026, it reported that Indiana’s Family and Social Services Administration (FSSA) had revoked Piece by Piece’s Medicaid provider agreements for all seven of its locations.

Shortly afterward, Piece by Piece announced it would shut down its operations. A competitor is in the process of acquiring it. Indiana’s FSSA secretary also demanded that all ABA providers self-report any fraud, waste, or abusive billing practices.

While billing practices are being scrutinized by states and investigators, broader reforms have been underway. When Indiana implemented a uniform reimbursement rate in 2024, spending fell by 27 percent without any reduction in the number of children served, suggesting that a substantial share of the prior spending had been inflated.

Other states have followed suit. Nebraska cut Medicaid payments for some ABA providers by nearly 50 percent. North Carolina decided to cut autism service reimbursement rates by 10 percent.

Though stronger oversight of Medicaid payments to ABA providers is necessary to safeguard the integrity of the system and protect the public’s funds from abuse, broad budget cuts to Medicaid support could harm the individuals the system is meant to help. Advocates assert that most ABA providers serve children with dedication and integrity, and that policymakers should focus on stopping fraud and abuse, not creating unintended harm for individuals, families, and responsible providers.

How Parents Can Evaluate the Quality of Their Child’s ABA Therapy

The Piece by Piece case is a reminder that high billing does not necessarily equal high quality. Parents can look for certain things when assessing whether their child’s ABA program is genuinely effective.

Confirm Who Oversees Care

Registered behavior technicians (RBTs) work directly with children but should be trained and actively supervised by BCBAs. Ask how often the BCBA observes sessions in person and to see a written supervision schedule.

Expect a Personalized Treatment Plan With Measurable Goals

Quality ABA starts with a thorough assessment of your individual child. Defining specific, measurable, achievable, relevant, and time-bound (SMART) goals is a foundational element of any legitimate ABA program. If a provider cannot clearly explain what your child is working toward and how progress will be measured, that is a warning sign.

Ask for Progress Data on a Schedule

High-quality ABA programs focus on consistent data collection, measurable progress, and active family involvement. Parents should request visual progress reports and ask for a full program review every three to six months. Behavior analysts should regularly meet with family members to review progress and adjust teaching plans as needed.

Watch for Skill Generalization

Therapy that only works in the therapist’s room isn’t fully realized. If your child masters a skill in therapy but cannot perform it at home or school, the goal is not yet fully met. Good ABA programs build in opportunities to practice skills across multiple settings.

Observe Sessions and Escalate Concerns

Parents deserve transparency and should feel empowered to ask questions about ABA programs, clinicians, and their children’s development. You have the right to observe sessions, ask about methodology, and request changes if something seems off. A quality provider will welcome your involvement. If concerns go unresolved after raising them with the therapist, escalate to the clinic director or your state’s Medicaid oversight agency.

Question Unusually High Session Volumes

Some children may benefit from intensive services, but intensity should be based on your child’s clinical needs and reviewed regularly — not set to the maximum covered amount.

Verify the Provider’s Accreditation

Look for ABA accreditation from a recognized body such as the Behavioral Health Center of Excellence (BHCOE) or the Commission on Accreditation of Rehabilitation Facilities (CARF). Accreditation means an outside organization has reviewed the provider’s practices against professional standards — a basic safeguard that many of the fraudulent providers in the Medicaid scandals lacked.

Bottom Line for Families

The alleged fraud and abusive billing concerns in Indiana and other states deeply harm vulnerable families and undermine public trust. But it should not overshadow the fact that well-delivered ABA therapy has helped many children with autism reach meaningful milestones. The goal going forward should be to hold bad actors accountable while ensuring that children who need this care can still access it.

If something feels off, seek a second opinion and contact your state Medicaid office for guidance.