The Trump administration and the Centers for Medicare and Medicaid Services deserve credit for taking Medicaid fraud seriously and working to strengthen its integrity. As they consider changes to Medicaid-funded autism services, it is important that the safeguards they implement protect taxpayer dollars while also preserving access to high-quality care for families who depend on these services. That balance will help ensure reforms target fraud and abuse without creating unintended challenges for legitimate patients and providers.
Applied behavior analysis, or ABA, is an evidence-based treatment that can help people with autism build skills in communication, social interaction, learning, and daily living. During ABA therapy, a behavior technician coaches children through specific activities that encourage this development. The skills developed during these sessions can be transformative.
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I know firsthand the extraordinary difference that ABA treatment can make for children with autism and their families. I have also watched with anger as unscrupulous providers in states such as Minnesota have exploited Medicaid autism benefits for their own financial gain. Unfortunately, Medicaid fraud is directly threatening access to this life-changing therapy for many who truly depend on it. Every dollar improperly paid to a fraudulent provider is a dollar that cannot be spent serving legitimate patients.
President Donald Trump and his administration are right to confront that abuse. The autism-services community should be their partner in that effort.
Recently, CMS released a tool kit to help states improve program integrity in Medicaid-funded ABA services. The tool kit rightly emphasizes that effective ABA therapy is individualized and that children deserve treatment plans based on medical necessity and clinical judgment. Now, as the administration considers next steps, it has an opportunity to build on this good work by ensuring any future reforms include three important elements.
One of the most immediate improvements would be strengthening the way Medicaid reviews claims before paying them. CMS already uses a tool known as Medically Unlikely Edits, or MUEs, to identify claims involving quantities of services that would be unlikely under normal circumstances. Yet, many state Medicaid programs do not make sufficient use of this basic safeguard. States should incorporate appropriate MUEs into their Medicaid claims systems so suspicious billing can be identified before taxpayer dollars are paid. A claim that exceeds reasonable parameters should trigger additional scrutiny and require substantiation. Legitimate providers should be able to document legitimate care. Those attempting to bill Medicaid for implausible amounts of services should face questions before they are paid, not after the fact.
States should also scrutinize excessive out-of-network spending. Medicaid managed care organizations are supposed to maintain networks of qualified providers who have gone through enrollment and validation processes and agreed to established reimbursement rates. When providers routinely operate outside those networks and submit substantially higher bills, taxpayers can end up paying far more than necessary.
The solution is to build strong networks that families can actually use. That requires reimbursement rates that are competitive enough to attract and retain qualified providers. If rates are set unrealistically low, legitimate providers leave networks, families face longer waits and travel farther for treatment, and out-of-network spending becomes harder to avoid.
The same principle should guide the way states approach limits on ABA services. While caps on weekly or monthly hours may seem like a simple way to curb excessive utilization, arbitrary limits could also restrict medically necessary care for children who need more intensive treatment. As CMS’s tool kit makes clear, decisions about the appropriate level of ABA services should be driven by medical necessity and each child’s individual needs — not a one-size-fits-all cap.
CONGRESS IS ABOUT TO DESTROY DECADES OF BRAIN INJURY RESEARCH IN ONE VOTE
A child should receive the amount of treatment and clinical supervision that is medically appropriate for that child, not whatever amount happens to satisfy an arbitrary quota. Medicaid should not pay for services merely because a regulation creates an incentive to provide them.
I am pleased the Trump administration is finally confronting fraud that has plagued Medicaid for years and hurt the good actors in our industry. But aggressive program integrity reforms can protect taxpayers while also preserving, and even improving, access to medically necessary autism treatment. And autism providers should work to help achieve this goal.
Steve Woolf is president of Butterfly Effects, a provider of Applied Behavior Analysis. Butterfly Effects is a member of the National Coalition for Access to Autism Services.