Ohio Autism Insurance Coalition’s Response To Recent Articles Published Detailing Federal Government Audits On ABA Providers And State Challenges For Clear Guidance For ABA Coverage

In a few state Medicaid programs, federal auditors have found a lack of state administrative rules and oversight, as well as likely improper payments made for Applied Behavior Analysis (ABA) services, the most prescribed evidence-based behavioral treatment for Autism Spectrum Disorder. The lack of state rules and consistent billing practices has led to recoupments. For Ohio, advocates and providers are issuing a preemptive warning: without clear state-approved administrative rules, Ohio could be vulnerable to the same.

Recent reports by both The Wall Street Journal and federal auditors have detailed fraud, waste, and abuse cases in Indiana and Minnesota. In one case, an Indiana provider collected $340,000 per patient—nearly ten times the national average—by exploiting a lack of state oversight and a reasonable, unstructured reimbursement schedule.

The Ohio Autism Insurance Coalition condemns fraudulent and wasteful billing and is speaking out and taking proactive steps to prevent similar cases in our home state – including billing for services not provided, the use of unqualified practitioners, reimbursement not based on cost and reasonable profits, and a lack of proper documentation supporting medically necessary services. Such actions lower access to services by betraying public trust, leading to the shrinkage of service infrastructure.

Now, the Ohio Autism Insurance Coalition argues that the primary culprit in some recent cases is not the treatment itself, but a lack of clear state administrative rules and a failure to use the industry-developed standards governing the delivery of ABA services as a guide for auditors when reviewing medical documentation for services.

While ABA treatment is one of Medicaid’s fastest-growing services nationwide, we need to remember it is a relatively new insurance-covered service, with many Ohioans with autism, now well into their teens or adulthood, never having access to behavioral treatments for their autism at a younger age. The coverage is just catching up to the real demand for these services, and Ohio currently lacks formal coverage within its Administrative Code.

“In states where there is a lack of clear, state-approved administrative rules, we see compliance confusion and possibly creating improper payments,” Marla Root, the founder of the Coalition and parent of an autistic adult, stated. “Ohio is currently operating in a vacuum where providers are forced to navigate a patchwork of different policies from each managed care organization rather than a single, high standard set by the state.” Advocates point to this lack of codified rules and reimbursement schedules as the exact environment in which “fly-by-night” operators could potentially thrive.

Without our state using the industry-agreed-upon standards of care, known as The Practice Guidelines by the Council of Autism Service Providers, and without state rules in Ohio regarding ABA coverage, auditors and OIG, facing these same issues in other states, often struggled to distinguish legitimate clinical documentation from improper billing practices.

In a move that distinguishes Ohio from the featured in national headlines, local ABA providers are actively lobbying for more, not less, regulation. The Coalition is throwing its weight behind legislative efforts, Ohio House Bill 453, sponsored by state Representative Brian Lorenz (Powell), which aims to professionalize the field and establish administrative rules based on industry standards. It will also codify the all-stakeholder-agreed-upon ABA reimbursement schedule developed from two completed cost surveys: one from the state’s ABA providers through the Coalition and the other from the Ohio Department of Medicaid’s actuarial firm.

“Ohio providers want high standards,” Root stated. “We are not waiting for a scandal to take action.”

To stay ahead of federal scrutiny, in early 2026, Ohio ABA providers participated in a series of intensive compliance and audit training sessions, along with workshops on proper medical-necessity documentation developed by the Ohio Autism Insurance Coalition. These programs are designed to ensure that every hour of treatment services billed is backed by the generally accepted standards of care” (The Practice Guidelines) – a benchmark that federal auditors say was missing in the states currently under investigation.

The concern among local families and ethical providers is that the national scandals could lead to a “knee-jerk” reaction in which legitimate services are slashed to cut costs.

In Arizona, hundreds of children recently lost access to care when Medicaid plans abruptly canceled contracts amid fraud concerns, resulting in a lawsuit from families. Ohio advocates argue that the only way to prevent a similar collapse here is to standardize the field now by establishing clear, enforceable rules for delivering this service within a medical model framework.

“These national issues don’t invalidate ABA as a life-changing treatment,” stated Jen Gonda, Director of Community BehaviorConsulting. Gonda is a certified Ohio behavior analyst and small business owner from Youngstown. “But they do prove that we need the state to step up and provide the guidance necessary to protect both Ohio’s autistic children and the taxpayers. We need the guardrails in place before the car goes off the road.” 

As the Ohio Department of Medicaid continues to review its ABA policies, which have been under development since 2008, and in light of the 2014 memo from the Center for Medicare & Medicaid Services stating that all states needed to offer ABA treatment coverage under Medicaid, the message from the autism community is clear: High standards and clear rules are the best defense against fraud, waste, and abuse.

The Coalition welcomes an opportunity to meet with stakeholders to improve Ohio’s delivery system for this medically necessary care. Please reach out by email at Help@ASDOHIO.com or by phone at 614-565-5765.