Maine Medicaid Flagged 89% of a Year of Autism Therapy Spending
Summary
A federal audit of Maine's Medicaid program for autism therapy found that all 100 sampled months of 2023 claims contained improper or questionable billing. Extrapolated across the year's audited caseload, the inspector general estimates the state paid at least $45.6 million in confirmed-improper claims and flagged another $22.4 million as potentially improper -- together, 88.7% of the $76.7 million Medicaid paid for the therapy that year. The confirmed-improper total alone equals 87% of the entire program's cost just four years earlier. Maine has never run a statewide check of these payments since the program began in 2010.
"Improper" and "potentially improper" are 's own two tiers, not interchangeable words for the same thing. A payment is confirmed improper when the documentation directly fails a specific rule -- no signed comprehensive assessment, no treatment plan, no record of the provider's credentials. A payment is potentially improper when the documentation is present but too vague or suspect to confirm the service happened as billed -- a session note that doesn't describe what was actually done, or that appears to include time spent on lunch or naps rather than therapy. treats the second category as needing further state review before anyone can say whether it, too, should be repaid.
Why undocumented therapy is not a paperwork problem
The state's own rules, in the MaineCare Benefits Manual, require a written record for every enrolled child: a comprehensive assessment, a signed individual treatment plan, and dated progress notes -- and require that specialized ABA-style services be delivered under the supervision of a licensed psychologist or a Board Certified Behavior Analyst. Those aren't audit inventions; they're the standard MaineCare set for itself. measured Maine's actual billing against that standard, and found 81 sampled months with a missing or unsigned assessment, 64 with session notes that didn't meet the documentation rules, 30 with a missing or unsigned treatment plan, and 20 -- spanning seven different providers -- where the paperwork didn't show the treating staff held the required credential at all.
doesn't treat this as bureaucratic housekeeping. Its own conclusion states the mechanism plainly: "cloned or otherwise unreliable session notes are an indication that children with autism may not have received the type of RCS services needed." A missing signature is a compliance defect. A session note that can't be trusted to describe what happened is a sign nobody can verify a child got the therapy Medicaid paid for.
View data as table
| Confirmed Improper | 45,638,476 | OIG recommends Maine refund the $28.8M Federal share |
|---|---|---|
| Potentially Improper | 22,440,690 | Still needs state review to determine if it's owed back too |
| Not Flagged | 8,636,371 | The remainder of the $76.7M audited population |
A program that outgrew its own oversight
MaineCare has covered RCS services for autism since April 1, 2010. In the sixteen years since, fee-for-service payments for the therapy nearly doubled just between 2019 and 2024 -- from $52.2 million to $103.8 million -- as more families sought and received the diagnosis-driven treatment. What didn't happen in those sixteen years, per , was a single statewide postpayment review: the state never systematically checked, across the whole program, whether the providers it was paying were following its own documentation and credentialing rules. The $45.6 million says Maine improperly paid in 2023 alone equals 87% of the entire program's yearly cost as recently as 2019.
View data as table
| 2019 | 52,200,000 | Before the audited period |
|---|---|---|
| 2023 | 80,600,000 | The audited calendar year |
| 2024 | 103,800,000 | The year after the audit period |
What Maine owes, and what it's agreed to
's four recommendations: refund the $28,796,366 federal share of the confirmed-improper payments; review the $14,163,521 federal share of the potentially improper payments and refund any of it that turns out improper too; give providers clearer documentation guidance; and start running the statewide postpayment reviews the program has gone without since 2010. Maine's Department of Health and Human Services agreed to the last three outright.
On the refund itself -- the $28.8 million -- the state's written response says only that it "potentially concurred," 's weakest tier of agreement short of outright disagreement, promising to review the flagged claims and repay only what those reviews confirm. 's published response is unambiguous: it "maintains" the recommendation is valid and continues to recommend the full $28,796,366 refund. Nothing in the report sets a deadline for Maine to complete that review, so whether the money comes back, and how much of it, is now a question with no clock attached.
Not just Maine
Maine is the third of four state audits has published in an identical exercise: the same 100-enrollee-month statistical sample, checked against the same categories of documentation failure, applied state by state to Medicaid ABA and RCS spending. Indiana's 2019-2020 audit found at least $56 million improper; Wisconsin's 2021-2022 audit found at least $18.5 million; Colorado's 2022-2023 audit⧉, published five weeks after Maine's, found at least $77.8 million.
In every single audit period, in every state examined, 100% of the sampled months contained a flawed claim. The failure mode repeats because the underlying design repeats: fast-growing therapy programs, billed in 15-minute increments, checked by no state against its own paperwork rules until a federal auditor shows up years later.
View data as table
| Wisconsin | 18,500,000 | 2021-2022 audit period |
|---|---|---|
| Maine | 45,638,476 | 2023 audit period |
| Indiana | 56,000,000 | 2019-2020 audit period |
| Colorado | 77,877,293 | 2022-2023 audit period |
- 88.7% of a year's spending, flagged. Of the $76.7 million Medicaid paid for Maine's autism therapy in 2023, estimates $45.6 million was confirmed improper and $22.4 million more was potentially improper -- leaving only about $8.6 million, roughly 11%, unflagged.
- The confirmed-improper total nearly equals the whole 2019 program. $45.6 million in flawed 2023 payments is 87% of what the entire RCS program cost Maine just four years earlier.
- Sixteen years, zero statewide reviews. MaineCare has covered this therapy since 2010 and, per , had never run a systemwide postpayment check before this federal audit -- and Maine has only "potentially" agreed to repay the $28.8 million federal share says it owes.
- This is the norm, not the exception. Indiana, Wisconsin, Maine, and Colorado have each been through the identical audit; each found 100% of its sampled months flawed.
This piece treats "improper" (a confirmed rule violation, per 's own finding) and "potentially improper" (documentation too incomplete or unreliable to confirm compliance, pending further state review) as defines them -- neither figure is an allegation of fraud, and 's report does not allege fraud; its findings describe documentation and oversight failures, and the $22.4 million potentially-improper estimate specifically requires further state-level review before any of it is confirmed as improper or collected.
Sources(2) ▾
- U.S. Department of Health and Human Services, Office of Inspector General, Office of Audit Services, Maine Made at Least $45.6 Million in Improper Fee-for-Service Medicaid Payments for Rehabilitative and Community Support Services Provided to Children Diagnosed With Autism (A-01-24-00006) (2026-01-16) — -'s audit of Maine's calendar-year-2023 fee-for-service Medicaid payments for rehabilitative and community support (RCS) services -- which include applied behavior analysis (ABA) -- provided to children diagnosed with autism. Source for the audited population size, the 100-enrollee-month sample, the improper and potentially improper payment estimates and their federal shares, the deficiency-category breakdowns, the credentialing gap, the finding that the state had never run a statewide postpayment review since the program began in 2010, the four recommendations, and Maine's response. oig.hhs.gov · original document
- U.S. Department of Health and Human Services, Office of Inspector General, Office of Audit Services, Colorado Made at Least $77.8 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children (A-09-24-02004) (2026-02-25) — The fourth report in -'s state-by-state Medicaid ABA audit series (after Indiana, Wisconsin, and Maine), used here only for its confirmed-improper-payment headline figure as a comparison point -- not for its Maine-specific findings, which are outside this piece's scope. oig.hhs.gov · original document
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Every one of the 100 case files the U.S. Department of Health and Human Services' Office of Inspector General⧉ sampled had something wrong with it. - -- the federal watchdog that audits how states spend Medicaid dollars and refers its findings back to Congress and the agency -- examined a year of MaineCare (Maine's Medicaid program) payments for rehabilitative and community support (RCS) services, the therapy category that includes applied behavior analysis (ABA) for children diagnosed with autism. Extrapolating from that sample across the full 2023 caseload, estimates Maine made $45.6 million in confirmed-improper payments and flagged another $22.4 million as potentially improper -- together, 88.7% of the $76.7 million Medicaid paid providers for the therapy that year.