(The Center Square) — After federal auditors found nearly $200 million in improper payments for autism-related services in four states, Louisiana is increasing scrutiny of a Medicaid-funded therapy whose costs have risen rapidly here and across the country.

Applied behavior analysis, or ABA, is a widely used treatment designed to help children with autism and other developmental disabilities improve communication, social and daily-living skills and reduce harmful behaviors.

The way the service is paid — often in 15-minute increments over sessions lasting hours — has created opportunities for questionable billing.

Louisiana Department of Health Secretary Bruce Greenstein said fraud investigations involving Minnesota’s autism-services program served as a “clarion call” for states to look more closely at providers considered particularly vulnerable to abuse.

Federal prosecutors this year charged two defendants in what the Justice Department called the largest Medicaid autism fraud case it has ever brought, alleging a $46.6 million scheme involving Minnesota’s Early Intensive Developmental and Behavioral Intervention program. Prosecutors said about $21.2 million was paid and alleged autism centers paid kickbacks to families and billed Medicaid for services that were never provided or were not reimbursable.

Separate federal audits have documented another problem: Medicaid paying for ABA when providers’ records did not adequately show that therapy was actually being delivered throughout the time billed.

The federal government estimated at least $56.5 million in improper ABA payments in Indiana, $18.5 million in Wisconsin and $77.8 million in Colorado. A Maine audit found another $45.6 million in improper payments for autism-related rehabilitative services that include ABA — a combined $198.4 million across the four audits.

Louisiana has not announced comparable findings of widespread improper ABA billing, though its investigation is still in the early stages.

Medicaid Executive Director Seth Gold told The Center Square that the state began an accelerated revalidation of high-risk providers in late spring and is now applying more stringent screening to ABA providers, which Louisiana had not previously classified as high risk.

“We’re now subjecting them to higher standards like on-site visits and background checks, fingerprinting, things like that, to make sure that we have a more rigorous review of who they are,” Gold said.

The state announced in June that it was expanding reviews of high-risk Medicaid providers, using additional data analytics and working more closely with the state Office of Inspector General to identify unusual billing patterns. High-risk providers can face more frequent revalidation, site visits and ownership reviews.

Gold acknowledged that Louisiana could have subjected ABA providers to heightened review sooner.

“I think we should have certainly been on top of this sooner in terms of that review,” Gold said.

Louisiana’s own spending has risen substantially, though not as dramatically as in some states.

Greenstein said state Medicaid spending on ABA has increased 41% over the past three years. Gold said the increase has been driven not by Louisiana raising its hourly reimbursement rate, but by more children receiving the therapy and by children receiving more hours of treatment.

Gold and his team are now looking at whether the state has proper and adequate controls over the therapy.

Gold said LDH is reviewing its policies around the number of treatment hours, medical-necessity reviews and whether children are showing meaningful progress. He said Louisiana wants the intensity of treatment to correspond to the child’s needs and, when appropriate, decline over time rather than remaining indefinitely at a high number of hours.

Greenstein described ABA as a treatment that should have measurable goals and an eventual exit strategy.

“This should not be an ongoing 40 hours a week for any kid that qualifies,” Greenstein said. “This really is a whole package of services that’s made to put itself to zero hours at the end of the service.”

Gold stressed that the increased scrutiny is not intended to eliminate a therapy that can be important for children who need it.

“The goal is making sure that the kids that do need these services can get them,” he said, while ensuring children receive only the level of therapy medically appropriate for them and eventually move to greater independence or other supports.