Colorado Made at Least $77.8 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children - February 2026

Sep 20, 2026

Uploaded by Jasmine

Audit results show that Colorado’s fee-for-service Medicaid payments for Applied Behavior Analysis (ABA) for 2022 and 2023 did not fully comply with Federal and State requirements. Of 100 sampled enrollee-months, every month included one or more claim lines that were improper or potentially improper. The audit found issues with documentation meeting requirements, staff credentials, and children’s diagnostic evaluation or referral documentation, plus potentially unallowable activities and incomplete session notes. Recommendations include refunds, improved guidance, and statewide postpayment reviews.

LanguageEnglish

CategoryResearch & Report

FormatPDF

Pages52

Reading Time2 h 11 min

AccessFree to download

INTRODUCTION

Why We Did This Audit

What OIG Found

What OIG Recommends

FINDINGS

CONCLUSION

RECOMMENDATIONS

STATE AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE

February 2026 | A-09-24-02004 Colorado Made at Least $77.8 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children OIG.HHS.GOV February 2026 | A-09-24-02004 Colorado Made at Least $77.8 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children Why OIG Did This Audit • Applied Behavior Analysis (ABA) is a therapeutic approach for managing the symptoms of autism and other developmental disabilities, usually centered on improving social and communication skills. • In the past several years, Federal and State agencies have identified questionable billing patterns by some ABA providers and payments to providers for unallowable ABA services. • Colorado’s fee-for-service (FFS) Medicaid payments for ABA in 2019 were $60.1 million, and by 2023 these payments had increased to $163.5 million. • This audit examined whether Colorado’s FFS Medicaid payments for ABA for 2022 and 2023 complied with Federal and State requirements. What OIG Found Colorado’s payments for ABA did not fully comply with Federal and State requirements. All 100 sampled enrollee-months included payments for 1 or more claim lines that were improper or potentially improper. What OIG Recommends We made five recommendations, including that Colorado refund $42.6 million to the Federal Government, provide additional guidance to ABA facilities for documenting and billing ABA, and periodically perform a statewide postpayment review of Medicaid ABA payments to educate providers on requirements. The full recommendations are in the report. Colorado disagreed with one recommendation. Colorado agreed with three recommendations, partially agreed with one recommendation, and detailed steps it has taken and plans to take in response to our recommendations. OIG.HHS.GOV TABLE OF CONTENTS INTRODUCTION ............................................................................................................................... 1 Why We Did This Audit ....................................................................................................... 1 Objective ............................................................................................................................. 2 Background ......................................................................................................................... 2 Medicaid Program................................................................................................... 2 Colorado’s Medicaid Program ................................................................................ 2 Applied Behavior Analysis ....................................................................................... 3 Colorado’s Medicaid Coverage of Applied Behavior Analysis ................................ 3 Providers’ Use of Procedure Codes for Billing Applied Behavior Analysis ............. 5 How We Conducted This Audit ........................................................................................... 7 FINDINGS......................................................................................................................................... 8 The State Agency Made Improper Payments for Applied Behavior Analysis................... 11 Federal and State Requirements .......................................................................... 12 Session Notes or Electronic Visit Verification Records Did Not Meet Documentation Requirements........................................................................... 13 Applied Behavior Analysis Was Provided by Staff Who Did Not Have Appropriate Credentials ..................................................................................... 17 Applied Behavior Analysis Was Provided to Children Without Documentation of the Required Diagnostic Evaluations or Treatment Referrals ....................... 17 The State Agency Made

FAQs

What was the audit objective regarding ABA Medicaid payments in Colorado?

The audit examined whether Colorado’s fee-for-service Medicaid payments for ABA for 2022 and 2023 complied with Federal and State requirements.

What did OIG find about Colorado’s ABA payments?

OIG found Colorado’s payments did not fully comply with Federal and State requirements, and all 100 sampled enrollee-months included improper or potentially improper claim lines.

What recommendations did OIG make in response to the audit findings?

OIG made five recommendations, including refunding $42.6 million to the Federal Government, providing additional guidance for documenting and billing ABA, and conducting periodic statewide postpayment reviews.

Sep 20, 2026

Uploaded by Jasmine