CMS signals heightened scrutiny of autism services

CMS has issued new guidance indicating a more rigorous review of claims for applied behavior analysis (ABA) and other autism services. The guidance highlights concerns over the medical necessity of intensive, long-term therapy regimens and calls for more robust documentation linking treatment plans to measurable functional outcomes. This move follows a 2025 OIG report that found significant vulnerabilities in Medicare and Medicaid payments for ABA services, including insufficient documentation and questionable billing patterns. Providers of autism and behavioral health services should anticipate increased prepayment reviews and potential post-payment audits. Monitor your local MAC bulletins for specific implementation details and prepare to strengthen clinical documentation that explicitly ties service frequency and duration to individualized patient goals.