Probe Reveals Autism Clinics Billed £600 Per Hour For Therapy That Could Be Delivered By High-School Graduates

An Indiana autism therapy provider billed Medicaid £600 ($800) per hour for sessions conducted by staff who needed only a high-school diploma to qualify, exploiting a billing loophole so gaping that it generated £22.3 million ($29 million) in taxpayer-funded revenue from just 84 children in a single year.

A Wall Street Journal investigation found that US Medicaid spending on Applied Behavior Analysis (ABA), the most widely prescribed therapy for children with autism, more than tripled from approximately £507 million ($660 million) in 2019 to £1.69 billion ($2.2 billion) in 2023.

The Council of Autism Service Providers, the sector's own trade body, acknowledged the findings in a formal statement, saying bluntly: 'Fraud, waste, and abuse occur in ABA — and it has to stop.'

The Indiana Loophole That Made One Provider Rich

At the centre of the Journal's investigation is Piece by Piece Autism Centers, an Indiana provider run by Meghann Mitchell. According to the Journal's analysis of billing records, the company received £22.3 million ($29 million) in Medicaid payments in 2023 to treat 84 children, an average of approximately £261,000 ($340,000) per child for the year.

At its peak, the company billed Indiana Medicaid at £1,230 ($1,600) per hour. After the state's automatic 60% discount, Indiana's programme at the time reimbursed providers at 40% of whatever they chose to bill, Piece by Piece still received £491 ($640) per hour.

The workers delivering the therapy were, in many cases, Registered Behavior Technicians (RBTs), a paraprofessional classification whose minimum requirements, per the Behavior Analyst Certification Board (BACB), are a high-school diploma or equivalent, a clean background check, and completion of a 40-hour training course. An 85-question exam follows.

The entire certification process can cost under £77 ($100). Workers in this role typically earn under £15 ($20) per hour, according to the Journal's reporting, meaning the gap between what a clinic paid its front-line staff and what it billed Medicaid could exceed £476 ($620) per hour.

Asked what specific costs justified such billing rates given labour costs as low as £15 ($20) per hour, Mitchell told the Journal: 'I really don't have an exact reason for that.' She told the newspaper her company complied with Indiana's rules, that state regulators never objected to her rates, and that audits had not found fraud.

The Journal noted that Mitchell subsequently purchased a £1.92 million ($2.5 million) home in Florida and paid off the mortgage shortly afterwards. Piece by Piece's £1,230 ($1,600) billing rate lasted only a few months before Indiana moved to a fixed reimbursement model; the state now pays a flat rate of £52 ($68) per hour.

Federal Auditors Found Errors in Every Single Claim Sampled

The scale of non-compliance has been confirmed across multiple government audits. The HHS-OIG audit of Indiana, published in December 2024, examined Medicaid ABA payments for 2019 and 2020. Its finding was stark: all 100 sampled enrollee-months included payments for one or more claim lines that were improper or potentially improper. The OIG recommended Indiana refund £30.3 million ($39.4 million) to the federal government and estimated a further £40.9 million ($53.2 million) in potentially improper payments requiring review.

The Colorado audit, published in March 2026, reached the same conclusion: all 100 sampled enrollee-months contained at least one improper or potentially improper payment. The OIG estimated £59.8 million ($77.8 million) in confirmed improper payments and a further £159.3 million ($207.4 million) in potentially improper ones. Colorado's Medicaid spending on ABA services had more than doubled, from £46.2 million ($60.1 million) in 2019 to £125.6 million ($163.5 million) in 2023. The OIG recommended Colorado refund £32.7 million ($42.6 million) to Washington.

Audits of Wisconsin and Maine told the same story: every sampled claim carried billing errors. Wisconsin was asked to return £9.4 million ($12.3 million) in confirmed improper federal share payments. Maine's OIG report, published in January 2026, found £35 million ($45.6 million) in improper payments. Common errors across all four states included lack of documentation, therapy sessions billed for non-therapy time, caregivers lacking appropriate credentials, and patients billed without a confirmed autism diagnosis on file.

The Wisconsin audit carried an additional detail that underscored the depth of the oversight failure: the state's Medicaid programme had never conducted a single post-payment review of ABA claims since the programme began in 2016. That is nearly a decade of billing without any state-level scrutiny of whether claims were legitimate.

Private Equity, Weak Standards and a Sector Under Pressure

The ABA therapy industry's rapid expansion attracted significant private equity interest. According to Becker's Behavioral Health, private equity firms acquired more than 500 autism therapy centres across the US over the past decade, with nearly 80% of those transactions occurring between 2018 and 2022. The Journal found that private equity-backed Action Behavior Centers billed Colorado's Medicaid programme for some of the most hours per patient of any autism provider in the state, a detail flagged in the OIG audit.

A Minnesota fraud prosecution added a sharper edge: a woman who took £10.8 million ($14 million) in Medicaid funds through an autism care scheme pleaded guilty in March 2026, according to Axios. Minnesota had 85 open investigations into autism providers as of last summer, following FBI raids on two providers in 2024.

The qualification gap at the heart of the billing issue is structural. Under BACB rules, an RBT needs a high school diploma and 40 hours of training to deliver direct ABA sessions. A supervising Board Certified Behavior Analyst (BCBA), by contrast, must hold a master's degree in behaviour analysis or a related field, complete hundreds of supervised fieldwork hours and pass a rigorous certification exam.

Yet the Journal found cases where clinics billed at rates implying specialist clinical input while sessions were delivered entirely by entry-level technicians earning £15 ($20) per hour or less.

Industry insiders have begun to speak openly about the unsustainability. Jeff Beck, co-founder and chief executive of ABA provider AnswersNow, told Behavioral Health Business: 'As an industry, we've dug ourselves into this hole. And the payers themselves have no empathy for the ABA providers who have been billing them 40 hours a week and £57,700 ($75,000) a year for the same kid for five years without any quality scores.'

States are now responding: Nebraska cut Medicaid ABA payments by up to 80%, North Carolina attempted a 10% reduction that was challenged in court, and UnitedHealth Group has limited ABA coverage in several states.

Hundreds of thousands of autistic children need this therapy; the evidence that some providers have been systematically overbilling for it has now reached every level of government, and the families caught in the middle had no part in building the mess.