Fraud and Harm at Autism Treatment Clinics

**Brian Lehrer** (0:10)
It's The Brian Lehrer Show on WNYC. I'm Tiffany Hanson, Infrabriant Today. Good morning again, everybody. All right, joining us now is Sarah Kliff, an investigative healthcare reporter at The New York Times. She and her co-reporter, Margot Sanger Katz, published a major investigation into how the applied behavior analysis therapy industry, which treats children with autism, has exploded into a multi-billion dollar business fueled by Medicaid dollars, private equity investment, and almost no regulatory oversight. Their reporting centers on complete kids, a fast growing chain of autism clinics in North Carolina. They found a pattern of over billing, over prescribed hours, and documented instances of child abuse. The investigation lands at a time when the Trump administration has identified autism therapy as a, quote, high priority focus for fraud enforcement. That according to Kliff's investigation.
Sarah Kliff, welcome back to WNYC. Glad to have you.

**Sarah Kliff** (1:17)
Thank you for having me back.

**Brian Lehrer** (1:19)
And listeners, we'd like you in this conversation as well. For those of you with children who are currently in that applied behavior analysis therapy, excuse me, that ABA therapy, we'd love to hear from you. What has your experience been like for your child? What does your child get out of attending an autism clinic that they wouldn't get out of attending in a school setting?
212-433-9692, you can call us, you can text us at that number. Okay, Sarah, you focused, as I said, your investigation on this complete kids clinic in North Carolina. You had an example you wrote about, a six-year-old girl who fell asleep in her therapist's lab and was woken up after seven minutes because it didn't comply with company policy. Naps can't go longer than seven minutes.
What, first of all, what does that tell us about how, that specific example, really tell us about how these clinics operate? And then what was it like for you to witness that?

**Sarah Kliff** (2:26)
Yeah, so the seven-minute figure, it's something we'd heard in our reporting, something that people who worked at the clinic were troubled by. And then we actually, like you mentioned, saw this little girl being woken up after falling asleep. And it struck us as an odd and relatively short amount of time for children to nap. But what we learned is that this behavior, applied behavior analysis, or ABA as it's often called, is typically built in 15-minute increments to Medicaid and other health plans. And a child has to be awake and performing therapy for the majority of that 15-minute increment. So the policy of this clinic is that after seven minutes, you need to wake them up so the child can be awake and performing therapy for eight minutes and that 15-minute unit can be billed to the health plan. So this really was rooted in billing and keeping the clock going on the billable hours for these children.
And we did visit one of the clinics and there was this incident where a girl did fall asleep and it was pretty tricky for her to wake up. Multiple people tried, she seemed pretty solidly asleep, but they did eventually get her up and that is the policy there. And they have defended this policy in our conversations, have said, look, in order to avoid committing Medicaid fraud, we have to keep the billing going and therefore we need to have a policy like this to keep ourselves safe.

**Brian Lehrer** (3:46)
Let's talk a little bit about how we got to this point. You said that in your article that nationwide, Medicaid spending on autism therapy has tripled, nearly tripled, between 2020 and 2024, and that in North Carolina specifically, so this area that you're focusing on, this complete kids in Concord, North Carolina. In the state of North Carolina specifically, that state projects it will spend over a billion dollars next year.
Now you talk about Colorado, for example, spending more on autism therapy than all of their emergency department visits combined. Talk to us about how we got here.

**Sarah Kliff** (4:28)
Yeah, so this was a therapy that's been around since the 1980s or so, when there were a few studies done by psychologists that were considered ground-breaking in a lot of ways. They showed with kind of intensive therapy that children with autism could change their behaviors. They could get help socializing and just acting in ways that are safe, not eloping, for example, running away is one that we saw them working on in the clinic we visited. So this therapy was developed in the 1980s. It didn't really become big business until the 2010s when a number of states, well-intentioned, passed mandates requiring insurance plans to cover this. The therapy can be very expensive. Families of children with autism really lobbied for this insurance benefit saying, we can't afford this if our insurance is not going to help.