Autism Treatment Fraud Defense &
ABA Therapy Fraud Defense
Former DOJ Fraud Section Prosecutors. Nationwide Defense for ABA Providers, BCBAs, Clinic Owners, Executives, and Medical Professionals Facing Federal Autism Treatment Fraud Investigations and Charges.
Based in Washington, D.C., Armstrong & Bradylyons PLLC defends ABA providers, Board Certified Behavior Analysts (BCBAs), Registered Behavior Technicians (RBTs), autism treatment clinic owners, healthcare executives, and medical professionals in federal autism treatment fraud and ABA billing fraud investigations and cases nationwide.
The firm’s healthcare fraud defense practice is built on nearly a decade of combined experience at the nation’s preeminent healthcare fraud enforcement unit: the Healthcare Fraud Unit of DOJ’s Fraud Section. Scott Armstrong, Drew Bradylyons, and Andrea Savdie tried 17 federal jury trials in healthcare fraud cases at DOJ’s Fraud Section involving over $2.8 billion in alleged false and fraudulent claims to federal healthcare programs. The firm uses that experience to defend providers, executives, and medical professionals at every stage of a federal case: from the first audit or grand jury subpoena, through federal indictment, and at trial.
The firm defends individuals in the districts where ABA enforcement is most active: Strike Force districts like the Southern District of Florida, the Southern District of Texas, the Central District of California, and the Eastern District of Michigan, and ABA-specific enforcement hot spots like the District of Minnesota, the Southern District of Indiana, the District of Colorado, the District of Maine, and the District of Massachusetts.
Armstrong & Bradylyons PLLC defends every autism treatment fraud case from the start as if it will go to trial. That is not a slogan. It is the operating principle of the firm, grounded in 25 federal jury trials in complex fraud cases in federal courts across the country.
Trial experience drives results at every stage. Healthcare fraud cases are won or lost on the quality of the factual record. The firm builds that record from the first day of engagement: analyzing claims data, retaining clinical experts, identifying and preparing witnesses, and developing a case theory that can withstand the government’s scrutiny.
The firm’s attorneys know how federal prosecutors build healthcare fraud cases because they built them. Scott Armstrong served for nearly a decade at DOJ’s Fraud Section, where he served as lead trial counsel in 16 federal jury trials, including complex healthcare fraud cases involving Medicare, Medicaid, and Tricare. Scott also directed DOJ’s Appalachian Regional Prescription Drug Task Force. Drew Bradylyons served as Chief of EDVA’s Financial Crimes and Public Corruption Unit and, before that, supervised the Healthcare Fraud Unit’s Miami Strike Force at DOJ’s Fraud Section. That combined experience provides the firm with an unmatched understanding of how federal healthcare fraud cases are investigated, charged, and tried.
The firm relishes the opportunity to try cases. Its willingness to go to trial and its proven skills at trial provide significant leverage in negotiations with federal prosecutors at every stage of an autism treatment fraud case.
Applied Behavior Analysis therapy is under a federal enforcement spotlight. The government is investigating ABA providers, clinic owners, and treating professionals at a pace and scale that did not exist three years ago. The enforcement wave is here.
Medicaid spending on ABA therapy grew from $660 million in 2019 to $2.2 billion in 2023. In some states, the growth was explosive. Indiana saw a 2,800% increase in ABA spending from 2017 to 2023. The number of ABA provider companies nearly doubled in the same period. The HHS Office of Inspector General (HHS-OIG) responded by launching a multistate audit series targeting Medicaid ABA payments. Every state audited so far has been found to have made tens of millions of dollars in improper payments. In Indiana, HHS-OIG identified at least $56 million in improper payments. In Wisconsin, at least $18.5 million. In Maine, at least $45.6 million. In Colorado, at least $77.8 million. In every audit, 100% of the sampled enrollee-months contained at least one improper or potentially improper claim.
The criminal side is moving just as fast. In Minnesota, the FBI raided two autism providers in 2024. State officials disclosed 85 open investigations into autism service providers. Federal prosecutors charged the first defendant in a $14 million autism therapy fraud scheme in September 2025. Additional defendants followed. In Massachusetts, the Attorney General indicted a Medicaid-enrolled autism provider for allegedly fabricating documentation to support over $1 million in false claims for ABA services that were never provided.
State Medicaid Fraud Control Units have publicly identified ABA therapy as a top enforcement priority. Federal prosecutors and HHS-OIG auditors are using claims data analytics, documentation reviews, credentialing audits, and cooperating witnesses to identify billing anomalies, target outlier providers, and build criminal cases. The Wall Street Journal published a major investigation in March 2026 exposing billing irregularities and overbilling in the Medicaid-funded autism therapy sector, further intensifying regulatory and enforcement scrutiny.
ABA providers, clinic owners, BCBAs, behavior technicians, and healthcare executives who operate in this space face real and immediate exposure to federal criminal and civil enforcement. Billing errors, documentation failures, and aggressive reimbursement practices that may have gone unnoticed for years are now under active federal scrutiny.
The firm’s autism treatment fraud defense practice is built on healthcare fraud trial experience, deep knowledge of Medicaid billing requirements and ABA clinical standards, and years of experience investigating and prosecuting complex healthcare fraud cases at DOJ’s Fraud Section. These tools are deployed at every phase of a case.
Challenging the Government’s Billing Analysis
Federal ABA fraud cases are built on Medicaid claims data. The government identifies outliers and presents statistical analyses to grand juries and trial juries. The firm challenges the government’s data at every level: the selection of comparators, the methodology used to identify outliers, the assumptions underlying extrapolation calculations, and the conclusions drawn from aggregate billing patterns. A billing anomaly is not fraud. The firm ensures that distinction is drawn clearly and forcefully.
Medical Necessity and Documentation Defense
The government’s case often hinges on the claim that services billed were not medically necessary, not properly documented, or not actually provided. The firm retains qualified ABA clinical experts to review treatment plans, session notes, and patient records. These experts can establish that the prescribed treatment intensity was clinically appropriate, that documentation met applicable CMS and state Medicaid requirements, and that the billed services were in fact rendered. Clinical expert testimony is critical to rebutting the government’s characterization of legitimate treatment as fraudulent billing.
Medicaid Billing Rules and CPT Code Defense
ABA billing is governed by a complex web of federal Medicaid requirements, state-specific billing rules, and CPT code definitions. The distinction between billable and non-billable time, the requirements for concurrent billing of technician and supervisor services, and the documentation standards for specific CPT codes vary by state. The firm analyzes the applicable billing rules and challenges the government’s interpretation of those rules. Regulatory ambiguity and inconsistent state guidance are powerful defense tools. Many claims the government characterizes as fraudulent are better explained by confusing or contradictory billing requirements.
Challenging the Government’s Proof of Knowledge and Intent
Federal healthcare fraud requires proof of willful and knowing fraud. Billing errors are not crimes. The firm builds the factual record to demonstrate that the provider acted in good faith, relied on existing compliance programs or professional guidance, and did not intend to defraud federal healthcare programs. Where the government relies on cooperating witness testimony to establish intent, the firm attacks the reliability, credibility, and motivations of those witnesses. The firm’s attorneys have extensive experience cross-examining cooperating witnesses in federal healthcare fraud trials.
Federal autism treatment fraud investigations target a range of individuals across the ABA industry: from the clinic owners and executives who built and operate ABA companies, to the licensed clinicians, behavior analysts, and technicians who deliver and supervise services. Armstrong & Bradylyons PLLC defends these individuals in federal investigations, after indictment, and at trial.
Defense of ABA Clinic Owners and Executives
The firm defends the founders, owners, and executives of ABA therapy companies and autism treatment centers in federal fraud and Anti-Kickback Statute investigations and prosecutions. Clinic owners are the primary targets of federal ABA fraud enforcement. Prosecutors pursue owners who allegedly directed or tolerated fraudulent billing practices, submitted claims for services not rendered, employed unqualified staff, paid kickbacks for patient referrals, or designed compensation structures that incentivized overbilling. The firm defends clinic owners against these allegations by challenging the government’s evidence of personal knowledge, direction, and intent.
Defense of Board Certified Behavior Analysts (BCBAs)
The firm defends BCBAs and other licensed supervising professionals in federal autism therapy fraud investigations and cases. BCBAs face criminal exposure when the government alleges that they signed off on treatment plans for patients they did not evaluate, approved session documentation without providing required supervision, or billed for supervisory services they did not actually perform. BCBAs may also be implicated when the government alleges that the treatment intensity they prescribed was not medically necessary or was designed to maximize billing rather than serve the patient’s clinical needs. The firm defends BCBAs by challenging the government’s clinical and billing theories and establishing the legitimate clinical basis for the professional’s decisions.
Defense of Registered Behavior Technicians (RBTs)
The firm defends Registered Behavior Technicians and other direct-service providers in federal autism treatment fraud investigations and cases. RBTs face criminal exposure when the government alleges that they fabricated session notes, reported services not actually delivered, inflated the duration of therapy sessions, or participated in schemes to bill for non-existent services. The firm defends RBTs by challenging the government’s evidence, attacking the credibility of cooperating witnesses, and establishing the technician’s good faith in performing their duties.
Defense of Physicians and Prescribing Professionals
The firm defends physicians, psychologists, and other licensed professionals who prescribe, refer, or authorize ABA therapy in federal investigations. These professionals face exposure when the government alleges that they issued diagnoses to patients who did not meet the criteria for autism spectrum disorder, prescribed treatment intensities that were not medically necessary, or received kickbacks in exchange for referrals to specific ABA providers. The firm defends prescribing professionals by challenging the government’s clinical evidence and establishing the legitimate medical basis for the professional’s diagnostic and treatment decisions.
Defense of Healthcare Executives and Investors
The firm defends healthcare executives, management company operators, and investors in ABA companies and autism treatment centers. Federal prosecutors and the False Claims Act are increasingly reaching individuals beyond the direct service providers: corporate executives, management services organization (MSO) operators, and in some cases investors who exercised operational control. The firm defends these individuals against fraud, conspiracy, and kickback charges arising from the operations of ABA provider organizations.
Federal autism therapy fraud investigations follow a pattern. Understanding that pattern is the first step to defending against it. Scott Armstrong and Drew Bradylyons built these types of cases as senior prosecutors at DOJ’s Fraud Section. They know how federal investigators identify targets, develop evidence, and present cases to grand juries.
Claims Data Analytics
The investigation typically begins with data. HHS-OIG, state Medicaid Fraud Control Units, and the FBI use sophisticated claims data analytics to identify billing outliers. They look for providers billing unusually high volumes of ABA hours per patient, providers with per-patient Medicaid reimbursement rates that far exceed peer averages, providers billing individual therapy codes when documentation reflects group activity, and rapid growth in claims volume that outpaces the provider’s disclosed workforce. These data-driven flags are what trigger the deeper investigation.
Documentation Audits
Once flagged, the government pulls medical records. HHS-OIG auditors and state MFCU investigators review session notes, treatment plans, prior authorizations, and clinical documentation line by line. The HHS-OIG audit series has revealed widespread documentation deficiencies across every state reviewed: session notes that lack sufficient detail to support billed CPT codes, missing or expired prior authorizations, unsigned or improperly signed session documentation, and billing for time spent on non-therapeutic activities such as meals, naps, or recreational activity.
Credentialing and Supervision Scrutiny
ABA services require qualified professionals. Medicaid programs require that ABA therapy be delivered by credentialed behavior technicians under the supervision of a licensed professional such as a BCBA. Federal investigators scrutinize whether the individuals who delivered services held the required credentials, whether required supervision was actually provided, and whether the supervising professional reviewed and signed off on treatment plans and session documentation. Cases involving unqualified staff delivering services that were billed as credentialed ABA therapy are a primary criminal enforcement target.
Patient and Employee Interviews
Federal agents interview current and former employees, parents, patients, and referral sources. They look for cooperating witnesses who can testify about the provider’s actual operations: whether services were actually rendered, whether session documentation was fabricated, whether staff were qualified, and whether the provider directed or encouraged fraudulent billing practices. Cooperating witnesses are a cornerstone of federal healthcare fraud prosecutions. They provide the narrative that connects data anomalies to individual intent.
Kickback and Referral Analysis
The government also investigates referral relationships. In autism therapy cases, federal prosecutors examine whether providers paid cash kickbacks to parents to enroll children, whether providers paid referral fees to physicians or other professionals for patient referrals, and whether patient recruitment practices violated the Anti-Kickback Statute (42 U.S.C. § 1320a-7b). Recent federal prosecutions have alleged that autism therapy providers paid monthly cash kickbacks ranging from $300 to $1,500 per child to parents who enrolled their children in ABA programs. These kickback allegations carry independent criminal penalties and also taint every claim submitted for services provided to those patients.
Search Warrants for Electronic Devices and Cloud Accounts
Federal agents routinely seek and execute search warrants for cell phones, laptops, tablets, and cloud-based accounts in ABA fraud investigations. These warrants target text messages, emails, iCloud backups, Google Drive contents, and messaging applications such as WhatsApp, Signal, and Telegram. The government is looking for communications between clinic owners, billing staff, BCBAs, and technicians that reveal knowledge of fraudulent billing practices, directives to fabricate documentation, discussions about kickback payments, and efforts to conceal conduct from auditors or regulators.
iCloud and Google account warrants are particularly powerful. A single cloud backup can contain years of text messages, photographs of documents, location data, and app data that the device owner may have believed was deleted. Federal agents obtain these warrants under 18 U.S.C. § 2703 of the Stored Communications Act and serve them directly on Apple, Google, and other service providers. The target of the warrant may not learn of its existence until well after the government has obtained and reviewed the contents. This evidence is often the most damaging material in a federal healthcare fraud prosecution. An experienced defense attorney can challenge the scope of the warrant, the manner of the search, and the admissibility of the evidence obtained.
Search Warrants for Electronic Medical Records and Patient Files
The government also executes search warrants and issues grand jury subpoenas to seize electronic medical records (EMRs) and patient files directly from ABA providers, EMR vendors, and practice management platforms. Federal investigators use EMR data to reconstruct the provider’s billing and documentation practices across the entire patient population. They compare session notes to billing records, analyze timestamps and metadata to determine whether documentation was created contemporaneously or fabricated after the fact, and identify patterns of copy-and-paste or templated notes that may indicate documentation was not individualized to the patient.
EMR metadata is a critical tool for federal prosecutors. It reveals when a session note was created, when it was last modified, who accessed the record, and whether the note was backdated. If an EMR system shows that session notes for dozens of patients were created in a single batch days or weeks after the dates of service, prosecutors will use that metadata to argue that the documentation was fabricated to support claims that had already been submitted. The firm understands how federal agents extract and analyze EMR data and challenges the government’s interpretation of that data at every stage of the case.
Federal autism treatment fraud enforcement is concentrated in specific districts. Some are traditional Medicare Fraud Strike Force districts with deep healthcare fraud infrastructure. Others have emerged as ABA-specific enforcement hot spots driven by state-level audit findings, explosive Medicaid spending growth, and high-profile criminal referrals. Armstrong & Bradylyons PLLC defends ABA providers in every one of these jurisdictions.
District of Minnesota
Minnesota is the most active federal ABA fraud enforcement district in the country. The U.S. Attorney’s Office for the District of Minnesota charged the first defendant in a federal autism therapy fraud scheme in September 2025. Additional defendants followed in December 2025. The FBI raided two autism providers in 2024. The Minnesota Department of Human Services disclosed 85 open investigations into autism service providers. The number of ABA providers in the state grew 700% in five years. From 2018 through 2025, all autism providers in total billed $1.6 billion across all DHS Medicaid programs. Minnesota is ground zero for federal ABA enforcement.
Southern District of Indiana
Indiana is the epicenter of the HHS-OIG ABA audit series. The state’s Medicaid spending on ABA therapy surged from $21 million in 2017 to $611 million in 2023. HHS-OIG identified at least $56 million in improper fee-for-service Medicaid payments to ABA providers. The U.S. Attorney’s Office for the Southern District of Indiana recovered $2 million in a civil settlement with an Indiana autism therapy provider for upcoded, concurrent, and duplicate claims. Indiana’s reimbursement structure, which previously paid providers 40% of whatever they billed, attracted intense federal scrutiny. Providers who operated in Indiana during the high-reimbursement period face significant exposure.
District of Colorado
Colorado is the most recent state to complete an HHS-OIG ABA audit. The March 2026 audit found at least $77.8 million in improper fee-for-service Medicaid payments for ABA services. Colorado’s Medicaid ABA spending grew from $60.1 million in 2019 to $163.5 million in 2023. As with every other state in the HHS-OIG audit series, 100% of sampled enrollee-months contained at least one improper or potentially improper claim. Colorado providers should expect criminal referrals and intensified MFCU enforcement activity following the audit findings.
District of Massachusetts
Massachusetts has emerged as a state-level ABA enforcement leader. The Massachusetts Attorney General’s Office indicted a Medicaid-enrolled autism service provider in June 2025 for allegedly fabricating documentation to support over $1 million in false claims for ABA services that were never provided. The Massachusetts MFCU has publicly identified ABA therapy as an area where fraud is rampant and has stated that it is regularly seeing fraud warranting criminal charges. Federal prosecutors in the District of Massachusetts coordinate with the MFCU and HHS-OIG on ABA fraud matters.
Southern District of Florida
The Southern District of Florida is home to one of the most active Medicare Fraud Strike Force teams in the country. South Florida has a long history of behavioral health fraud enforcement, from sober home cases to partial hospitalization program fraud. ABA providers operating in South Florida face scrutiny from both the Strike Force and HHS-OIG. The district’s enforcement infrastructure, experienced federal prosecutors, and high volume of healthcare fraud cases make it a high-risk jurisdiction for ABA providers.
Southern District of Texas
The Southern District of Texas is a Strike Force district with an aggressive healthcare fraud enforcement posture. Texas is one of the largest Medicaid ABA markets in the country, and rapid provider growth has drawn federal attention. Strike Force prosecutors in Houston coordinate with HHS-OIG and state regulators on behavioral health and ABA fraud investigations. Providers operating in Texas face exposure from both federal Strike Force prosecutors and the Texas Medicaid Fraud Control Unit.
Central District of California
The Central District of California is a Strike Force district with significant behavioral health fraud enforcement activity. California is the largest Medicaid market in the country, and its ABA spending has grown substantially. Federal prosecutors in Los Angeles have experience with complex behavioral health fraud cases involving billing for services not rendered, unqualified staff, and kickback schemes. ABA providers operating in Southern California face enforcement risk from the Strike Force, HHS-OIG, and the California Department of Justice.
Eastern District of Michigan
The Eastern District of Michigan is one of the original Strike Force districts and has a deep bench of experienced healthcare fraud prosecutors. Michigan has experienced significant growth in ABA Medicaid spending, and the state’s enforcement infrastructure is well developed. The Detroit Strike Force team coordinates closely with HHS-OIG on healthcare fraud matters across the behavioral health spectrum, including ABA therapy.
District of Maine
Maine is one of three states to have completed an HHS-OIG ABA audit. The January 2026 audit found at least $45.6 million in improper fee-for-service Medicaid payments for rehabilitative and community support (RCS) services provided to children diagnosed with autism. HHS-OIG recommended that the state refund $28.7 million in federal share to the federal government. The audit found that all 100 sampled enrollee-months contained at least one improper or potentially improper claim. Common deficiencies included session notes that lacked sufficient detail to support the billed service, missing signatures, and documentation that did not support the number of units billed. Maine’s audit findings mirror the systemic problems identified across the HHS-OIG audit series and create a foundation for criminal referrals and MFCU enforcement.
Additional Districts
ABA fraud enforcement is not limited to the districts above. Wisconsin has been the subject of an HHS-OIG audit identifying at least $18.5 million in improper ABA payments. North Carolina saw ABA Medicaid spending projected to grow 423% from 2022 to 2026, prompting rate cuts and heightened scrutiny. Nebraska cut ABA reimbursement rates by nearly 50% for some providers. HHS-OIG has announced plans to audit additional states. Federal and state enforcement activity in this space is expanding rapidly. Scott Armstrong and Drew Bradylyons defend ABA providers in every federal district where DOJ, HHS-OIG, and state MFCUs bring autism treatment fraud cases.
Federal autism treatment fraud prosecutions draw on several criminal statutes. The charges carry severe penalties. Understanding the statutory framework is essential to mounting an effective defense.
Healthcare Fraud (18 U.S.C. § 1347)
The primary charging statute in ABA fraud cases. Healthcare fraud makes it a federal crime to knowingly and willfully execute or attempt to execute a scheme to defraud any healthcare benefit program. In autism treatment cases, this statute targets the submission of false claims for ABA services not rendered, services rendered by unqualified staff, and services that were not medically necessary. The penalty is up to 10 years of imprisonment per count. If the fraud results in serious bodily injury, the maximum increases to 20 years. If it results in death, a life sentence is possible.
Wire Fraud (18 U.S.C. § 1343)
The government frequently charges wire fraud alongside or as an alternative to healthcare fraud. Wire fraud applies to any scheme to defraud that uses interstate wire communications, which includes the electronic submission of Medicaid claims. Wire fraud carries a maximum penalty of 20 years of imprisonment per count and a maximum of 30 years when the fraud affects a financial institution.
Anti-Kickback Statute (42 U.S.C. § 1320a-7b)
The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving anything of value to induce or reward the referral of patients for services covered by federal healthcare programs. In autism treatment cases, prosecutors target cash kickbacks paid to parents to enroll children, referral fees paid to physicians or diagnostic professionals, and compensation arrangements with patient recruiters. Violations carry up to 10 years of imprisonment per violation. Each claim submitted for a patient referred through a kickback arrangement is also an independent false claim.
False Claims Act (31 U.S.C. §§ 3729–3733)
The False Claims Act is the government’s primary civil enforcement tool. It imposes liability on any person who knowingly submits or causes the submission of false or fraudulent claims to the government. In ABA fraud cases, the FCA targets claims for services not rendered, upcoded services, and services tainted by kickback relationships. Penalties include treble damages and per-claim penalties ranging from $13,946 to $27,894 per false claim. FCA cases may be brought by the government directly or by private whistleblowers through the Act’s qui tam provisions.
Conspiracy (18 U.S.C. § 371)
Conspiracy is charged in nearly every multi-defendant ABA fraud case. It requires proof that two or more persons agreed to commit a federal offense and that at least one overt act was taken in furtherance of the conspiracy. Conspiracy carries a maximum penalty of five years of imprisonment. When the object of the conspiracy is healthcare fraud or wire fraud, the penalties of the underlying offense also apply.
Federal Program Exclusion and Collateral Consequences
Beyond incarceration and fines, a conviction or even a settlement in an autism treatment fraud case triggers mandatory exclusion from Medicare, Medicaid, and all federal healthcare programs under the authority of HHS-OIG. For BCBAs and other licensed professionals, exclusion effectively ends a career. State licensing boards may also initiate independent disciplinary proceedings. These collateral consequences are often as devastating as the criminal penalties themselves.
What Should I Do If I Am Under Investigation for ABA Therapy Fraud?
Retain experienced federal defense counsel immediately. Do not speak with federal agents, HHS-OIG auditors, state MFCU investigators, or anyone else about the investigation before consulting a defense attorney.
Federal ABA fraud investigations frequently begin with an HHS-OIG audit, a grand jury subpoena, agent contact from the FBI or HHS-OIG, a state Medicaid Fraud Control Unit inquiry, or the suspension of Medicaid payments. What you say and produce in the early stages of an investigation shapes the entire case. Premature statements to investigators, voluntary production of records without legal review, and cooperation with state auditors without understanding the criminal implications can cause irreversible damage.
An experienced defense attorney will communicate with the government on your behalf, advise on the scope of any subpoena or audit, protect privileged information, and develop a defense strategy before charging decisions are made. Scott Armstrong and Drew Bradylyons defend ABA providers and autism treatment professionals at the investigation stage and at trial, drawing on years of experience as senior prosecutors at DOJ’s Fraud Section.
What Types of ABA Billing Practices Trigger Federal Investigations?
Federal investigators target specific billing patterns and practices in ABA fraud cases. The most common triggers include billing for ABA services not actually rendered to the patient, billing for individual therapy when the actual service was group-based, upcoding technician services as higher-level BCBA supervisory services, billing for excessive treatment hours that are not supported by the patient’s clinical needs, billing for time spent on non-therapeutic activities such as meals, naps, and recreational activity, and concurrent billing for technician and supervisor services that were not actually provided simultaneously.
The HHS-OIG multistate ABA audit series has found that the most common documentation deficiencies involve session notes that lack sufficient detail to support the billed CPT code, missing or expired prior authorizations, and unsigned or improperly authenticated documentation. These findings form the basis for both civil recoveries and criminal referrals.
What Are the Penalties for a Federal Autism Treatment Fraud Conviction?
The penalties are severe. Healthcare fraud (18 U.S.C. § 1347) carries up to 10 years of imprisonment per count. Wire fraud carries up to 20 years per count. Anti-Kickback Statute violations carry up to 10 years per violation.
Beyond incarceration, defendants face substantial fines, restitution orders, and forfeiture of assets derived from the fraud. Federal law mandates exclusion from Medicare, Medicaid, and other federal healthcare programs upon conviction. For BCBAs, RBTs, and other credentialed professionals, exclusion effectively ends the ability to practice. State licensing boards and the Behavior Analyst Certification Board (BACB) may also initiate independent disciplinary proceedings based on the underlying conduct.
On the civil side, the False Claims Act imposes treble damages and per-claim penalties. Given the volume of claims in ABA cases, civil FCA exposure can reach tens of millions of dollars. A conviction or settlement can end a career permanently.
Can a BCBA Lose Their Certification Over a Fraud Investigation?
Yes. A federal healthcare fraud investigation places a BCBA’s certification, professional license, and career at risk before a conviction.
The Behavior Analyst Certification Board maintains its own disciplinary process. A federal criminal charge, a civil FCA settlement, or even the underlying conduct alleged in a fraud investigation can trigger BACB review and potential revocation of certification. State licensing boards may initiate parallel proceedings. Federal program exclusion by HHS-OIG prevents a provider from billing any federal healthcare program.
These parallel proceedings create a minefield for the unwary. A defense attorney experienced in healthcare fraud understands how to navigate criminal, civil, and regulatory proceedings simultaneously to protect both a provider’s liberty and livelihood.
What Is the HHS-OIG ABA Audit Series and Why Does It Matter?
In 2022, the HHS Office of Inspector General announced a series of audits targeting Medicaid payments to ABA providers in multiple states. The audits are designed to determine whether state Medicaid programs are making proper payments for ABA services provided to children diagnosed with autism.
To date, HHS-OIG has completed audits in Indiana, Wisconsin, Maine, and Colorado. The findings have been stark. In every state, 100% of the sampled enrollee-months contained at least one improper or potentially improper claim. The total improper payments identified across the completed audits now exceed $198 million. HHS-OIG has recommended that states refund tens of millions of dollars to the federal government and implement enhanced oversight and postpayment review systems.
These audit findings have direct enforcement consequences. They identify systemic billing problems that federal prosecutors can use to support criminal investigations. They also generate referrals from HHS-OIG to DOJ and state Medicaid Fraud Control Units. ABA providers in states that have been audited, or that are likely to be audited next, face heightened exposure.
What Medical Documentation and Billing Issues Does the Government Target in ABA Fraud Cases?
Federal investigators and HHS-OIG auditors focus on specific documentation and billing elements in ABA fraud cases. The government targets deficiencies in treatment plans, session notes, prior authorizations, CPT code documentation, credentialing records, and supervision logs. Understanding what the government looks for is critical to defending against fraud allegations.
CPT code documentation. ABA therapy is billed using Current Procedural Terminology (CPT) codes. The codes most frequently at issue in federal investigations are CPT 97153 (adaptive behavior treatment by protocol, delivered by a behavior technician), CPT 97155 (adaptive behavior treatment with protocol modification, delivered by a qualified healthcare provider such as a BCBA), and CPT 97156 (family adaptive behavior treatment guidance). The government scrutinizes whether session notes contain sufficient detail to support the specific CPT code billed and the number of units claimed.
Session notes and treatment records. Every billable ABA session must be supported by contemporaneous session notes that document the specific interventions delivered, the patient’s response, the duration of service, and the identity and credentials of the treating professional. The HHS-OIG audit series has found that session notes frequently lack the detail necessary to support the billed service. Notes that are vague, templated, or that describe non-therapeutic activity such as meals, naps, or recreational time do not support a billable ABA claim.
Prior authorizations and treatment plans. Medicaid ABA services require a prior authorization based on a comprehensive diagnostic evaluation and an individualized treatment plan (ITP). The treatment plan must be developed by a qualified supervising professional and must set forth specific goals, interventions, and the prescribed intensity of treatment. The government examines whether the prior authorization was current, whether the treatment plan was individualized to the patient, and whether the billed services were consistent with the authorized plan of care (POC).
BCBA supervision logs. ABA services delivered by behavior technicians must be supervised by a Board Certified Behavior Analyst or other qualified supervising professional. The government investigates whether required supervision was actually provided, whether supervision logs are accurate and contemporaneous, and whether the supervising professional reviewed and signed off on session documentation. Claims billed under CPT 97155 for supervisory services require documentation showing that the BCBA was physically present and actively modifying the treatment protocol.
Credentialing and staff qualifications. Medicaid programs require that ABA services be delivered by individuals who meet specific credentialing requirements. Registered Behavior Technicians (RBTs) must hold current certification through the Behavior Analyst Certification Board. Federal prosecutors target providers who employed individuals without the required credentials to deliver services that were billed as credentialed ABA therapy. The HHS-OIG audits have specifically flagged claims where the treating individual lacked appropriate credentials as improper.
A defense attorney experienced in ABA billing can challenge the government’s interpretation of documentation requirements and establish that the provider’s documentation practices were consistent with applicable state and federal standards.
What Defenses Are Available in a Federal ABA Therapy Fraud Case?
The available defenses depend on the specific allegations. Common defenses in ABA fraud cases include the following:
Lack of intent to defraud. The government must prove willful and knowing fraud. This is an extremely high burden. Billing errors, documentation gaps, and negligent oversight are not crimes.
Medical necessity. Defendants can challenge the government’s claim that ABA treatment intensity was not medically necessary. Clinical documentation, treatment plans, patient progress data, and expert testimony from qualified behavior analysts support this defense.
Good faith reliance. Reliance on the advice of compliance consultants, billing companies, or legal counsel can negate the element of intent.
Regulatory ambiguity. ABA billing rules vary by state and are often vague or contradictory. Where the government characterizes a billing practice as fraudulent, the defense can demonstrate that the practice was a reasonable interpretation of ambiguous rules.
Challenging data analysis. The government relies heavily on statistical methodologies and claims data analytics. These can be challenged on their underlying assumptions, inputs, comparators, and conclusions.
Scott Armstrong and Drew Bradylyons leverage their significant federal trial experience as former prosecutors to anticipate the government’s trial strategy and develop an aggressive, evidence-based defense.
What Is the Difference Between a Civil and Criminal ABA Fraud Investigation?
Civil ABA fraud investigations focus on recovering money. These may involve False Claims Act actions, Civil Investigative Demands (CIDs), and penalties including treble damages and per-claim fines. HHS-OIG audit findings frequently support civil recovery actions.
Criminal ABA fraud investigations focus on proving intentional and willful fraud beyond a reasonable doubt. Criminal cases carry the possibility of imprisonment, criminal fines, and restitution.
The government frequently runs civil and criminal investigations in parallel. The same conduct can expose a provider to both civil liability and criminal prosecution at the same time. This is one of the most dangerous dynamics in healthcare fraud enforcement. Statements and concessions made in a civil matter or audit response can be used to build a criminal case.
Experienced defense counsel ensures that a provider does not make statements or concessions in a civil or audit context that can be used to trigger or advance a criminal investigation. Scott Armstrong and Drew Bradylyons have years of experience navigating parallel civil and criminal healthcare fraud cases at DOJ’s Fraud Section and as defense attorneys.
Can a Clinic Owner Be Held Personally Liable for Fraud by Employees?
Yes. Federal prosecutors regularly pursue clinic owners and executives for fraud committed within their organizations. The owner does not need to have personally submitted false claims. If a provider causes another person to submit a claim with knowledge that the claim is false or fraudulent, a criminal case against that provider may be viable.
The government relies on theories of conspiracy (18 U.S.C. § 371) and aiding and abetting (18 U.S.C. § 2) to reach individuals beyond those who directly submitted the false claims. Prosecutors examine whether the owner had knowledge of, directed, or willfully ignored the allegedly fraudulent conduct.
An experienced defense attorney challenges the government’s proof of knowledge and personal involvement. Scott Armstrong and Drew Bradylyons built these cases for years at DOJ’s Fraud Section and now use that experience to challenge the government’s theories of executive and owner liability.
Why Is ABA Therapy Under Federal Enforcement Scrutiny Now?
Three factors converged. First, Medicaid coverage for ABA therapy became universal across all 50 states by 2022, driven by CMS guidance requiring coverage of comprehensive autism services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Second, the industry experienced explosive growth. Direct Medicaid payments to ABA providers grew from $660 million in 2019 to $2.2 billion in 2023. The number of ABA provider companies nearly doubled. Third, regulatory oversight did not keep pace with the growth.
The combination of massive federal spending, rapid industry expansion, inconsistent state oversight, and high per-patient reimbursement rates created conditions that federal enforcers view as ripe for fraud. HHS-OIG launched its multistate audit series. State MFCUs identified ABA therapy as a priority enforcement area. DOJ began criminal prosecutions. The Wall Street Journal published a major investigation. The enforcement cycle is now fully engaged.
Does Armstrong & Bradylyons PLLC Handle ABA Fraud Cases Outside of Washington, D.C.?
Yes. Armstrong & Bradylyons PLLC defends individuals in federal autism treatment fraud investigations and prosecutions nationwide. The firm can practice in every federal district court in the country.
ABA fraud investigations and prosecutions are concentrated in states with the highest Medicaid ABA spending and the most significant billing anomalies, including Indiana, Minnesota, Colorado, Wisconsin, Texas, Florida, and California. Federal prosecutions originate from both U.S. Attorney’s Offices and DOJ’s Health Care Fraud Strike Force, which operates across multiple districts.
Scott Armstrong and Drew Bradylyons have tried healthcare fraud cases and handled investigations in Strike Force districts and federal courts across the country. The firm is based in Washington, D.C. and represents clients in every jurisdiction where DOJ, HHS-OIG, and state MFCUs investigate and prosecute autism treatment fraud cases.