Medicaid autism therapy boom triggers crackdown

State of play: The focus is a form of intensive, personalized therapy called applied behavioral analysis that's mostly aimed at young children to help them learn social skills and reinforce positive behavior.

• Demand for the services has surged, along with Medicaid reimbursement rates, which are higher than other behavioral health services, the Wall Street Journal recently reported.
• It's causing a fiscal crunch in states like Nebraska, where spending on the therapy grew 2,000% in five years.
• Private equity firms have acquired more than 500 autism therapy centers over the past decade, mostly in states with higher rates of autism diagnoses that have fewer limits on insurance coverage.

Providers say the lack of widely accepted guidelines for autism care and the fee-for-service reimbursement system is creating openings for overbilling.

• "There are some children who need a 25-, 30-, 35-hour program. A lot do not," said Neil Hattangadi, CEO of Cortica, an autism care company that offers applied behavioral analysis alongside other services.
• "Everyone getting indiscriminately high volumes ... that's what's driving up the cost."
• Federal health watchdogs have identified tens of millions of dollars in improper payments for applied behavioral analysis in Colorado, Wisconsin and Indiana.

Zoom in: Private equity-backed Action Behavior Centers billed Colorado's Medicaid program for some of the most hours per patient of any autism provider, the Wall Street Journal review of Medicaid data found.

• There's also been outright fraud: A Minnesota woman who took $14 million in Medicaid funds in an autism care scheme pled guilty this month.

Where it stands: States and Medicaid managed care plans are scrutinizing more autism program spending and imposing cost controls.

• Nebraska cut Medicaid payments for applied behavioral analysis by up to 80% last year. Indiana policymakers have proposed payment caps and reduced rates. New York is considering legislation that would make similar changes.
• Medicaid managed care insurers like UnitedHealth Group have also limited coverage for applied behavioral analysis in some states.

Yes, but: The changes are causing significant upheaval for families that have been using applied behavioral analysis.

• One mother in Arizona told Axios Phoenix that her 3-year-old son spent eight months on a waitlist for services before he got into a program last year.
• Their insurance plan has since removed the provider from its network. The mother said she'll probably have to quit her job when her son loses coverage for his 40-hour-a-week therapy in May.
• North Carolina reversed some cuts to Medicaid payment for applied behavioral analysis services last year after families of kids with autism sued the state.

Between the lines: The focus on autism therapy spending coincides with Health Secretary Robert F. Kennedy Jr.'s push to identify a "cure" for the neurodevelopmental condition and his promoting widely discredited links to vaccines.

• "There are providers that are legitimate and good and providers that are not," said Eli Brottman, a political consultant for Democrats who has autism.
• "What I'm more concerned about is that we have a president who repeatedly stigmatizes people with autism and pedals false claims that are designed to further marginalize us and harm us."

What we're watching: What kind of role Kennedy's Department of Health and Human Services plays in oversight going forward.

• HHS didn't respond to a request for comment from Axios.