OPINION:
Congress just exposed a huge hole in Medicaid oversight, and it is too big for state leaders across the country to ignore.
On Sept. 29, the House Energy and Commerce Committee released its findings from an investigation into how the government tracks healthcare spending. The report found that our government writes checks first and asks questions later, routinely missing red flags such as providers billing for more hours than there are in a day or clinics treating an implausible number of patients.
Taxpayers lose billions of dollars.
People were interested in these podcasts
The committee’s report particularly highlighted the numerous payments made for applied behavior analysis without adequate checks and balances to prevent fraud.
Applied behavior analysis primarily treats children with autism and developmental conditions, teaching them essential life skills. It is important but expensive, and the high price tag of this treatment has naturally attracted fraudsters’ attention.
Tax dollars flow into these programs based on paperwork written by the very companies getting paid. By skipping independent medical reviews and strict progress checks, the system has opened the door wide to overbilling, sloppy tracking and waste.
The committee found that “Between 2021 and 2025, Medicaid spending on applied behavior analysis services for children with autism grew six times faster than the number of children receiving the service, increasing 421% from $2 billion to over $10 billion per year nationally.”
In Florida, the issue is especially pronounced. From 2021 to 2025, Florida spent more than $2.1 billion on applied behavior analysis therapies for patients who were never formally diagnosed with autism. That is more than every other state in the nation combined.
The amount of money the state has allocated to applied behavior analysis services through its Medicaid managed-care system was based on a deeply flawed understanding of the number of state residents using the service. This overfunding shifted more than $300 million away from general pediatric care in the state.
The federal government — in particular, Centers for Medicare & Medicaid Services Administrator Mehmet Oz and Medicaid Director Dan Brillman — has the power to fix these funding problems in Florida and nationwide.
CMS controls the purse strings for state Medicaid programs, meaning no state can change how it funds services such as applied behavior analysis therapy without the agency’s approval. CMS can simply refuse to sign the checks until states prove that they have real safeguards against fraud in place.
Because insurers accept providers’ internal treatment plans and notes without an independent second opinion, the system effectively allows providers to grade their own papers. Without strict and independent checks before payouts happen, we leave the door wide open to waste, fraud and abuse.
Instead of letting 50 different states make their own rules — and their own mistakes — the federal government should use its leverage to force nationwide improvements all at once.
Congressional Republicans have already put these systemic vulnerabilities under a microscope. Now, CMS should step up and use the authority Congress already gave it to restore real accountability to Medicaid.
That is the best way to protect both taxpayers and the children who truly need help.
• Joseph R. Pitts is a former chair of the House Energy and Commerce Committee’s subcommittee on health.
Please read our comment policy before commenting.