Medicaid spending on core ABA services increased by 403% from 2019 to 2024. A review of one major federal payment database reveals which organizations have been on the receiving end of that spending.
Publicly available Medicaid data show that the autism industry has moved from an obscure niche to a mainstream, established market. It also reveals a remarkably fragmented industry with few truly dominant entities and payment practices by states and payers that created wide disparities.
Payments to Farmington Hills, Michigan-based Centria Healthcare, the top recipient of Medicaid funding, accounted for 3.9% of all spending on select autism therapy-related services in 2024, as disclosed in the database. Salt Lake City, Utah-based ABS Kids was fairly close behind at 3.4%, according to an analysis of this data by Behavioral Health Business.
Spending on direct therapy, protocol modification, and group and individual family training across all states grew by about 403% from 2019 to 2024. The number of provider entities delivering these services to Medicaid recipients increased 346%. This suggests that much of the spending increase is driven by new providers opening their doors.
The dataset, originally released in February by the U.S. Department of Health and Human Services (HHS) and Department of Government Efficiency initiative (DOGE), provides a rare snapshot of autism therapy-related Medicaid spending at both the national and provider-specific levels. Other initiatives have examined spending at the state or national level without specifying provider organizations.
“The data reflect the significant and continued growth in demand for autism therapy services within Medicaid populations we serve and is mirrored across the country,” Jeffrey Skibitsky, the founder and president of ABS Kids, told BHB. “They also illustrate the increasing importance of Medicaid as a critical access point for children and families seeking evidence-based autism care.”
The data does not capture a full picture of autism therapy spending in Medicaid. To comply with federal privacy laws, the data published online does not include providers with 12 or fewer claims or total patients. It may also undercount organizations billing under multiple NPIs.
The data is derived from the Transformed Medicaid Statistical Information System (T-MSIS), the system through which the U.S. Centers for Medicare & Medicaid Services collects data from the states and American territories. By definition, it excludes private health insurance claims. This analysis is also narrowly limited to four core services that make up the heart of ABA and does not look at the other supportive services that many providers take on to give patients holistic services.
Top-paid ABA providers
BHB reached out to the providers that appear in these lists. The few providers that did respond noted the accuracy of our compilation of data available for the services we searched for in the data. Our analysis is based on 178,684 records from the roughly 238-million-row data set.
The top-20 companies by total Medicaid reimbursement show stark differences among the highest earners. The top four all-time highest-paid companies are mature enterprises that have been serving their respective markets for a decade or more in some instances. Centria Healthcare was founded in 2009, while its autism division (Centria Autism) was launched in 2010. ABS Kids was founded in 2011. Lighthouse Autism Center was founded in 2012. Hopebridge was founded in 2005.
While the top four highest payment-getters — Centria Healthcare, ABS Kids, Lighthouse Autism Centers, Hopebridge — are all backed by private equity, only three other firms among the top-20 list have PE backing. Those firms are Caravel Autism Health, LEARN Behavioral and Acorn Health.
Ten of the top 20 all-time funding-getters are founder- or family-owned:
— CompleatKidz
— Piece By Piece Autism Center
— Positive Behavior Supports Corp.
— Brett DiNovi & Associates
— Behavior Interventions, Inc.
— Applied Behavior Center for Autism
— Chitter Chatter P.C.
— Matrix Behavior Solutions
— Bridgeway Integrated Healthcare Services
— Stepping Stones Behavioral Solutions
“(Positive Behavior Supports) is a private BCBA-owned business that is not backed by private equity and has experienced various changes in the field over our 20 years of being in business,” Positive Behavior Supports founder and CEO Dr. Michael Nolan, who is also a BCBA-D, told BHB. “We understand that this is an evolving field that has attracted attention from investors and that, sadly, the field has been a target for fraud, waste, and abuse. … We believe that both business owners and taxpayers would benefit from a standardized approach that ensures that families have access to needed services for years to come.”
Many of the top-paid providers across the data also have a large, multi-state footprint. Those that do not have a state-specific focus that makes the organization worth noting, especially organizations based in Indiana.
Until Jan. 1, 2024, autism therapy organizations that operated under the Indiana Medicaid program were allowed to effectively set their own rates. The state would reimburse up to 80% of the billed amount. That lax approach led to organizations submitting and the state reviewing and approving very high reimbursements. This, in large part, helped to kick off the present narrative about potential abuse in Medicaid autism benefits.
Among the top 20 all-time highest-paid providers, five are headquartered in Indiana. Those that focused their businesses on the state — Stepping Stones Behavioral Solutions, Piece By Piece Autism Center and Applied Behavior Center for Autism — saw huge swings in payments in 2024 compared to 2023 when comparing the first 10 months of the year (November and December 2024 data appears to be missing). Piece By Piece saw a 96% decrease; Stepping Stones saw a 67% decrease, while Applied Behavior Center saw a 30% decrease.
“Unlike many providers, (Applied Behavior Center) has historically focused on serving children with the most severe and complex autism-related needs,” Sherry Michael, the founder and CEO of Applied Behavior Center for Autism, told BHB. “To my knowledge, we are the only ABA provider in Indiana whose primary focus is serving this population. As a result, our patients often require significantly higher levels of care, greater staffing ratios, more intensive treatment plans, and longer treatment durations than those seen by many other providers.”
Today, the company employs 500 people and serves about 350 patients in Indiana. It also maintains that it is the largest privately owned ABA provider in the state. It lists 21 centers on its website. Applied Behavior Center also offers speech and occupational therapy.
“Because of our focus on children with severe autism and complex behavioral needs, higher utilization of services is often reflective of patient acuity and clinical necessity rather than provider size or operational structure alone,” Michael said. “One thing I have always said is, ‘Regardless of what is charged, the most expensive services are those that fail to produce long-lasting outcomes.’”
Piece By Piece Autism Center shut down in May after the Indiana Family and Social Services Administration revoked its provider agreement following an investigation by the Wall Street Journal that found that it had some of the highest rates in the nation. Applied Behavior Center for Autism took over its operations. Our analysis found that its average claim per session encounter across all data available for Piece By Piece Autism Center was $1,379.92 for direct therapy — by far the highest among the top 50 highest-paid providers — and was the second-highest for protocol modification, sometimes called supervision, at $566.96 per claim. Applied Behavior Center for Autism agreed to pay $2 million to resolve a false claims investigation in 2023.
Across all providers, session claims average $198.56 for direct therapy and $155.87 for supervision.
Top 20 most patient episodes
The companies that generated the most patient-months match pretty closely with those that accrued the most payment over the span of the data, with minor exceptions.
Since the data provided by HHS does not depublicate on the basis of unique patients, it’s not possible to get a snapshot of the largest providers on the basis of patients served. However, raw clinic output, at least in terms of paid claims, can be assessed by looking at claim lines.
From this perspective, the largest and most mature providers in the industry stand out even among the largest.
Centria Healthcare operates in 11 states, has 64 treatment locations and offers home-based services. Caravel Autism Health was founded in 2009 and operates 77 locations in nine states. Caravel declined to comment for this story.
“For us, success is measured by the outcomes we achieve, not just about how many families we serve,” Timothy Yeager, chief clinical officer of Centria Healthcare, told BHB. “Across the validated assessments we use to track developmental progress and skill acquisition, including the Vineland-3, VB-MAPP, ABLLS, and AFLS, Centria clients rank in the top 90th percentile of progress in communication, socialization, and daily living skills when benchmarked against industry data through the National Autism Data Registry.”
Many of the providers on the list focus on clinic-based models. However, Positive Behavior Supports Corp. focuses on in-home care. It was founded in 2007. The company operates in 32 states, serves about 9,000 families and employs about 6,500 people.
“Our services are delivered in the home and community so that skills are learned and practiced within the natural settings,” Nolan told BHB. “By avoiding a clinic-based model, we eliminate the common barrier of having to transfer skills from a controlled environment to real life.”
Positive Behavior Supports Corp. says that its average weekly treatment totals about 14 hours — 11 hours of direct treatment and three hours for “analysis” and caregiver training, Nolan said.
These data show that billing for parent training claims among the top earners accounts for a negligible share of their work. Positive Behavior Supports’ rate of parent training relative to all claims examined is about 2.6-times higher than the average. Nolan told BHB its rate of parent training is four times the national average.
Average payment per claim for therapy
The top funding-getters in the data typically command a premium for direct therapy and protocol management services. Excluding outliers among the 50 highest-paid providers, the all-time average of direct therapy payment per claim is about 17% higher than the average, while protocol modification claims command a 35% premium compared to the average.
Similar to other measures discussed, this is a function of several factors in combination, especially which state the provider operates in and its clinical practices. In some states, like California and Pennsylvania, there is an added layer of oversight and engagement where local entities have a role in contracting and overseeing Medicaid benefits. Those local entities, such as counties, also contract out the actual administration to behavioral health managed care organizations. This adds yet another layer of potential variability.
“This is not an informal or unstructured system,” Wick Khan, cofounder and CEO of East Stroudsburg, Pennsylvania-based Matrix Behavior Solutions, told BHB.
The company operates five centers and serves 14 of the Eastern-most counties in the state.
“At Matrix, our focus from day one has been to provide quality services and invest in our employees,” Wick said. “Our ultimate success measure is when a child no longer needs our services and is able to independently use the skills learned. This goal is inspired by our personal experience as parents and watching our own sons become more independent.”