U.S. federal authorities have implemented a comprehensive toolkit to curb rising costs and questionable billing in autism therapy, as state and industry scrutiny intensifies over rapid clinic expansion and billing scandals.
Medicaid spending on autism therapy has risen sharply over four years, reaching about $10 billion in 2025 from roughly $2 billion in 2021, according to reporting cited by The New York Times. The increase far outpaced the growth in autism diagnoses, and spending per child more than doubled over the same period, raising fresh questions in Washington and in state capitals about whether the system is delivering care efficiently and appropriately.
In response, federal Medicaid officials have issued a 173-page toolkit aimed at tightening state oversight of autism clinics. The guidance urges states to place limits on how much therapy a provider can bill before giving a child a break, to require prior authorisation when high numbers of hours are prescribed and to monitor clinic outcomes more closely. Caprice Knapp, a senior Medicaid policy official, told The Times that officials had seen “quite an explosion in costs” and wanted to ensure “the profit motivation isn’t overtaking what’s in the best interest of children.”
The new push comes after a Times investigation found thousands of autism clinics had opened nationwide with little regulatory scrutiny. Former and current workers told reporters that some employers encouraged excessive therapy hours and, in some cases, urged families to take children out of school so clinics could bill more time. The investigation also described billing practices in North Carolina that included highly controlled schedules around 15-minute payment blocks, and it said some private equity-backed operators had expanded rapidly into the sector.
The federal guidance also challenges a common industry view that 30 to 40 hours of weekly therapy is always necessary. It says 40-hour weeks are not a best practice and have not been shown to produce better outcomes for every child, while leaving too little time for basic activities such as eating, toileting and sleep. The Council of Autism Service Providers maintains that 30 to 40 hours can be appropriate in comprehensive treatment plans, and its chief executive, Lori Unumb, said in a statement that not every child needs that level of therapy but that clinicians should make the decision individually.
States are already moving ahead with their own controls. North Carolina, for instance, is heading towards spending $1 billion on autism therapy next year, up from $121 million in 2022, and has passed a law requiring special review of treatment plans when weekly therapy exceeds 16 hours. Other states, including Indiana, Colorado, Wisconsin and Maine, have reported audits flagging billing for non-therapeutic activities such as lunch and playground visits. Dan Brillman, who oversees Medicaid for the Trump administration, told The Times that every state faces the same challenge and that the new guidance is intended to help governors and Medicaid directors work with legislators on solutions.
Disclaimer: This content is for informational purposes only and is not intended to be a substitute for professional medical judgment, advice, diagnosis, or treatment.
