AI Alert May 2025

Fighting Bad Behavior: Addressing Fraud, Waste, and Abuse in Applied Behavior Analysis

As Applied Behavior Analysis (ABA) services for autism spectrum disorder continue to grow, so does the risk of fraud, waste, and abuse (FWA). With the implementation of the Mental Health Parity and Addiction Equity Act of 2008, ABA coverage expanded significantly. Between 2011 and 2017 alone, employer-sponsored plans saw a 376% increase in spending on ABA services. But as coverage and utilization rose, so did opportunities for billing abuse—highlighted by high-profile cases such as Early Autism Project Inc., which paid an $8.8 million settlement for false claims submitted to Tricare and South Carolina Medicaid.  

For health plans, it’s more important than ever to have robust Payment Integrity (PI) and Special Investigation Unit (SIU) strategies in place to detect and address misuse of ABA services. 

What are the most common procedure codes for billing ABA therapy? 

ABA therapy relies on a set of procedure codes that distinguish assessment, treatment, and supervision services. Some plans or provider-specific contracts may allow other HCPCS codes to represent ABA therapy, such as “H” codes. Check your health plan’s policies and guidelines for ABA therapy to see which procedure codes are allowed based on setting and specialty. The table below contains a list of the most common procedure codes for ABA therapy.  

Table 1: ABA therapy procedure codes 

CodeProcedure Description
97151 Behavior identification assessment by a QHP, per 15 min 
97152 Supporting assessment by a technician, per 15 min 
97153 Adaptive behavior treatment by a technician, per 15 min 
97154 Group adaptive behavior by a technician, per 15 min 
97155 Protocol modification by a QHP, per 15 min 
97156 Family guidance by a QHP, per 15 min 
97157 Multi-family group guidance by a QHP, per 15 min 
97158 Group adaptive behavior w/ protocol modification, per 15 min 
0362T Complex assessment requiring QHP & multiple techs, per 15 min 
0373T Complex treatment w/ QHP supervision, per 15 min 

What are some red flags that would prompt a review of an ABA therapy provider and their claims? 

Certain billing behaviors may indicate potential FWA and as such, health plan SIU teams should look for: 

  • Lack of supervision (CPT 97155) when a high-volume of CPT 91753 is billed for a patient 
  • Missing or minimal parent training (97156) 
  • Impossible hours per day, such as >24 hours per day if the provider is a solo practitioner 
  • Billing on holidays, weekends, or during extreme weather 
  • Unlicensed or uncredentialed rendering providers 
  • Duplicate billing for technician and QHP services 
  • Billing for services in prohibited settings, such as Place of Service 03 (School) in New York 

What are Payment Integrity audit triggers for ABA therapy claims? 

ABA therapy service provider profiles and billing patterns could lead to potential FWA and as such, health plan PI teams should review: 

  • Registered Behavior Technician services without required BCBA/QHP supervision 
  • Improper licensing (e.g., NY requires an LBA in addition to BCBA) 
  • Outlier billing patterns by providers compared to peer groups 

What are some internal controls to improve oversight and reduce potential FWA? 

  • Thorough authorization reviews – especially for reassessments 
  • Robust policies and procedures, including a formal ABA provider manual 
  • Compliance with state-specific Medicaid rules, such as:
    • CA: Reassessments every 6 months; supervision ratio rules 
    • NY: No services in schools (POS 03); strict licensure enforcement 

What are some examples of fraudulent practices uncovered in ABA therapy reviews?  

  • No in-person supervision – BCBAs attending meetings, not sessions 
  • Supervision via video review – not compliant with face-to-face requirements 
  • Cloned documentation across multiple patients 
  • Billing for non-clinical activities (e.g., training staff, religious instruction) 
  • School-based services billed despite no treatment being rendered 
  • Siblings billed separately for care delivered simultaneously by one technician 

How can Fraud Scope assist your health plan with identifying potential FWA with ABA therapy?   

Advanced analytics tools like Fraud Scope are critical in proactively identifying suspicious patterns. Below are a few features that can assist health plans with identifying ABA providers and therapy services for additional review.  

  • Pattern recognition using AI to flag unusually high volumes, time overlaps, or unsupported service combinations 
  • Outlier detection by comparing providers to peer norms by procedure code 
  • Query Builder to create specific audit scenarios 

As ABA services evolve, so must our strategies to protect the integrity of healthcare funds. The combination of analytics-driven oversight, state-specific regulatory understanding, and targeted investigative efforts ensures payers are well-positioned to detect, prevent, and recover from abusive billing practices. 

Let’s continue fighting bad billing behavior – with better billing behavior analysis. 

Resources and Regulatory Guidance 

State Licensure Boards 
Not all states have a licensure board for behavior analysts. Refer to the BACB map for details: 
BACB U.S. Licensure of Behavior Analysts 

New York State Guidelines 

California State Guidelines 

Federal and Industry Reference Materials