Fraud Isn’t Committed by the Child, But the Child Pays the Price

Silueta de un niño mirando por una ventana al atardecer

Series: The System I See — Entry No. 01

By a grandfather with more than ten years in the ABA field.

I’m a grandfather of three, one with special needs. I’ve spent more than ten years connected to the field of Applied Behavior Analysis (ABA), among other things as a cofounder of several companies and in particular of iCMS, a tool built to help improve service quality and protect the efficient use of public funds directed toward ABA. I’m not writing this from a clinical office or with a title behind my name. I’m writing from what I’ve seen, in my own family and over a decade of watching closely how this system works, and how it fails.

I want to start this series with a simple idea. The ABA system faces several real problems at once today, and the response to fraud, however necessary, often ends up hitting the children who need the service most.

Real growth, not a trend

Over the last decade, diagnoses of autism (ASD) and ADHD have grown steadily. CDC data show that ASD prevalence among 8 year olds went from 1 in 44 in 2021 to 1 in 36 in 2023, and more recent estimates, using 2022 data, place the figure at 1 in every 31 children. This isn’t overdiagnosis for its own sake. There’s greater clinical awareness and better detection tools, even though access remains uneven.

Add to that comorbidity. A significant share of children with ASD also have ADHD, with studies reporting ADHD rates within the autistic population ranging from 15% to over 30%, depending on the sample and diagnostic method. A child with both conditions isn’t simply “twice as complex” on paper. It’s a case that requires more clinical time, more coordination across disciplines, and more documentation to justify to insurers.

The bottleneck the pandemic left behind

Children who were 2 or 3 years old in 2020, the ideal age for early detection, saw that window close during the pandemic. The evidence documents that COVID-19 disrupted routine pediatric visits and early evaluation services, delaying the identification of ASD cases, and that disparities in autism screening persisted throughout the pandemic’s first year.

The result, a few years later, is a backlog of cases. Children who should have been evaluated in 2020 and 2021 didn’t get a formal evaluation until 2022 or 2023. The bottleneck we’re living with today isn’t just a supply problem. It’s, in part, the delayed bill from a health crisis that interrupted early detection right when it mattered most.

The communities with less access are still the same ones

This is something I’ve seen up close, and it’s rarely told with enough honesty. Families from less advantaged communities, particularly those where English isn’t the language spoken at home, face an added barrier that the system isn’t solving. Many non English speaking families lack providers who speak their native language to guide them through the steps toward diagnosis and intervention.

In a place with a large Spanish speaking population and other language communities, this isn’t a minor detail. It’s a structural gap that determines, in practice, who gets therapy in time and who doesn’t.

The minimum bar to certify whoever sits in front of the child is low

The Registered Behavior Technician, the RBT, spends more direct hours with the child than any other professional on the team. And today that credential is earned through 40 hours of training, completed in a minimum of 5 days, plus a competency assessment and an exam. That’s a low bar of entry for the responsibility being handed over.

This isn’t a criticism of individual RBTs, many of whom do dedicated, careful work. It’s a question about how the system is designed. When the minimum entry requirement is this low, service quality depends almost entirely on how much each provider invests in supervision, ongoing training, and staff retention.

The arrival of investment funds, and their business model

Private equity funds are buying up ABA companies at a growing pace, drawn by a steady revenue stream backed by insurance and Medicaid. Journalistic and academic evidence documents a consistent concern among parents and clinicians, that the focus on profitability has degraded care quality at private equity owned providers, pushing models that prioritize billable hours over each child’s therapeutic goal.

Fraud isn’t committed by the child on the waiting list. It isn’t committed by the family that’s waited two years for an evaluation. It isn’t committed by the well trained RBT who does their job with dedication.

And then the response to fraud arrives

AHCA has rightly stepped up its fight against fraud in Medicaid. In June 2026, the agency’s secretary stated publicly that, over the past two years, it had terminated or denied enrollment to more than 3,200 providers, and recovered or prevented more than 136 million dollars in improper payments. Between 2018 and its lifting in November 2022, Florida maintained a multi year moratorium on new ABA provider enrollments in Miami Dade and Broward, after detecting falsified credentials and fraudulent billing.

The fraud is real, and it’s been documented across multiple states. No one should downplay this.

The problem isn’t fighting fraud. It’s how it’s fought.

During the four years it was in effect, a moratorium across two entire counties didn’t distinguish between the provider who falsified credentials and the new, honest provider who wanted to open a center to serve families on a waiting list. But when the regulatory response is built with the width of a blanket ban instead of the precision of a scalpel, it’s the small honest providers who end up paying the cost.

What’s coming in this series

The real impact of the moratorium, what changes as ABA moves into Statewide Medicaid Managed Care, the barriers Spanish speaking families face, and what it means for service quality when investment capital sees these children as a revenue line.

Sources and notes

The opinions expressed in this article are strictly personal to the author and do not represent the position, policies, or interests of any company, organization, provider network, insurer, or entity the author is or has been affiliated with, including iCMS. This content is offered for informational and public opinion purposes, is based on the publicly cited sources above, and does not constitute legal, clinical, or financial advice, nor an accusation against any specific person, company, or institution. The patterns and examples described are general in nature and do not correspond to identifiable clinical, family, or administrative cases.