Audits Spotlight Unusual Trends In Medicaid Spending For Autism Care
Authored by Sylvia Xu via The Epoch Times,
One in 31 U.S. children has an autism diagnosis. Among Minnesota’s Somali community, that number jumps to one in 12.
That discrepancy made headlines last fall when the Department of Justice charged a Somali woman with netting millions in fraudulent autism services.
Now, state and federal investigators are putting autism spending in the spotlight.
The September 2025 federal indictment alleged that a therapy center—run by 28-year-old Asha Farhan Hassan—recruited Somali children for an autism services program that was then reimbursed by Medicaid.
The White House pointed to the indictment on March 16 in an executive order announcing the creation of a federal task force to eliminate fraud.
“The staggering fraud and waste in Minnesota alone is a case in point,” the order reads.
“There is also strong reason to believe that similar problems exist in other States, including California, Illinois, New York, Maine, and Colorado.”
Nationwide, Medicaid spending for autism therapy services increased by over 200 percent between 2018 and 2024—nearly four times the rate of overall Medicaid spending. In some states, the increase was much higher.
The surge is linked to what Health and Human Services Secretary Robert F. Kennedy Jr. has called an autism epidemic, including “an alarming escalation in case severity, and increasingly stark disparities across racial and ethnic groups.”
However, investigators say the rise in spending can’t be explained by the increase in diagnoses or escalation in severity alone.
Meanwhile, a series of federal audits has drawn attention to four states where auditors found millions in “improper” or incorrectly billed payments for Medicaid-funded autism services.
Here is a look at states that have uncovered higher-than-usual Medicaid spending for autism services.
Minnesota
Since 2018, Minnesota has spent more than $18 billion on 14 Medicaid programs considered “high risk” for fraud, Assistant U.S. Attorney Joe Thompson said in December.
More than $9 billion of that money went to fraud, Thompson estimated, announcing another autism related indictment.
The state’s Early Intensive Developmental and Behavioral Intervention program, which treats children under 21 with autism spectrum disorder, is under particular scrutiny.
It’s the coverage framework for services like applied behavior analysis, a major part of the program.
Applied behavior analysis is a widely used behavior therapy, primarily used with children who have been diagnosed with autism or other developmental disorders. It can include teaching children to follow directions or practicing communication or social skills. Registered behavior technicians usually administer the therapy, supervised by more highly trained behavior analysts.
On March 17, Minnesota released the results of its own audit investigating allegations of kickbacks in the state’s autism services program.
For over 30 years, the report said, the state’s definition of “fraud” has not included kickbacks.
“While DHS could have acted at any time to revise its rules, it has permitted the error to stand since 1995, limiting its authority to address kickbacks,” the report said.
Meanwhile, the cost of the state’s autism early intervention service increased nearly 1,600 percent from 2019 to 2024, according to a March report from the House Committee on Oversight and Government Reform.
Enrollment ballooned by more than 620 percent during those years.
A state-commissioned report from United Health Group’s Optum division found Minnesota could have saved more than $1 billion in autism early intervention costs between January 2022 and October 2025, if officials had clarified ambiguous policies. An addendum to the January report revised that number to $703 million.
An investigation revealed patterns of claims that didn’t match clear policies or procedures.
“If the pre-payment system being developed now had been in place at the time, these items would have been flagged for further review and payments paused, until additional investigation was completed,” John Connolly, deputy human services commissioner and state Medicaid director, said in February.
“This is not a measure of fraud, waste and abuse, but it shows us where we need to do more work to understand why these claims are raising red flags,” Connolly said in a statement.
Nebraska
Nebraska’s Medicaid spending for applied behavior analysis increased notably over a similar time period. It grew by 1,700 percent from 2020 to 2024, according to a report last fall from the state’s Health and Human Services department.
The number of companies providing applied behavior analysis services nearly quadrupled, growing from 10 to 38 over the four years.
The number of behavior analysts and technicians billing for autism services in the Cornhusker State rose by 761 percent from 2019 to 2024—higher than Minnesota’s rate of growth in that area, which was 646 percent, according to a December report from Trilliant Health, a health care analytics company.
The payment rates in Nebraska were the highest in the nation, according to the Nebraska Department of Health and Human Services.
“We found that Nebraska’s rates for these services have been significantly higher, some more than twice as high, as those of other state Medicaid programs,” said Drew Gonshorowski, Medicaid and long-term care division director for the department.
A behavior technician in Nebraska earned $36.11 per 15-minute unit in 2024. That’s slightly more than $144 an hour, and 130 percent higher than the national average.
Behavior technicians typically undergo 40 hours of training and must have a minimum of a high school diploma.
In August 2025, the state agency reduced Medicaid payment for a behavior technician by 48 percent, bringing the rate from $36.11 to $18.70 per 15-minute unit, or $74.80 per hour.
North Carolina
In North Carolina, spending on autism therapy is projected to exceed $1 billion over the next two years.
Medicaid spending on applied behavior analysis in the state grew by 347 percent from 2022 to 2025, North Carolina Medicaid deputy secretary Melanie Bush reported in a joint legislative oversight committee meeting March 10.
“Nothing here can answer the question of where that growth rate is coming from,” state Sen. Ralph Hise said during the meeting.
Spending growth was concentrated among a small number of providers and far outpaced growth in new provider enrollment, according to a report from the North Carolina Department of Health and Human Services.
Utilization growth also increased faster than the autism diagnoses, the report said.
While total Medicaid enrollees receiving applied behavior analysis services grew by 249 percent over the four years, the number of 15-minute service increments increased even more, by 305 percent.
“Utilization growth far outpaces increases in Autism Spectrum Disorder (ASD) diagnosis,” the report said, adding that it’s “unlikely that this level of growth can be explained by increased access alone.”
Massachusetts
MassHealth, the Medicaid and children’s health insurance program for Massachusetts, overpaid autism service providers $17.3 million in 2024, according to an audit report from the state’s Office of the Inspector General.
The state’s spending on autism services rose 36 percent between 2021 and 2023, according to the 2024 report.
State rules require that a licensed applied behavior analyst provide at least one hour of supervision for every 10 hours of therapy given by a technician.
Nearly $16.8 million was overpaid because the therapy provided was over that ratio and should not have been billed, the audit found.
Further, from 2018 to 2022, behavior technician roles in the state grew at twice the pace of licensed supervisor positions, at 129 percent and 52 percent, respectively.
When applied behavior analysis is not properly supervised, it undermines the quality of care for vulnerable children and results in the waste of public funds, the audit concluded.
Federal Audits
At the federal level, the HHS Office of Inspector General is investigating services and billing patterns for Medicaid applied behavior analysis services provided to children with autism.
The audits, which began in 2022, have been completed for four states: Colorado, Indiana, Wisconsin, and Maine. Three other audits remain in progress.
The federal agency estimated nearly $200 million in improper payments and more than $400 million in potential improper payments for these states.
The completed audits found payments that were improper or potentially improper in 100 percent of reviewed claims. That was often due to inadequate records, such as missing progress notes, lack of supervision logs, or billing issues.
However, the audits also uncovered problems that could affect the quality and safety of care, such as criminal convictions for weapons offenses, assault or driving under the influence.
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