By Jaymie Baxley
Meredith McCumbee has seen firsthand the difference applied behavioral analysis therapy, commonly known as ABA, can make in children with autism.
Aaron, her 16-year-old son, was diagnosed with autism and apraxia of speech — a disorder that makes it difficult to coordinate the muscle movements needed to form words — in 2014. His inability to communicate growing up often led to aggressive “meltdowns,” his mother said, creating a near-constant state of crisis at home.
“My husband and I were exhausted,” said McCumbee, who lives in New Hanover County. “We were always in reactive mode, and it was a struggle, an absolute struggle, to balance [that with] parenting, working full time and maintaining relationships with family and friends.”
The couple saw a marked improvement in Aaron’s behavior after he began receiving ABA therapy, which is designed to help children with autism build communication and daily living skills through intensive one-on-one interventions. He can now express his feelings, ask for assistance and advocate for himself in a constructive way, McCumbee said.
“ABA didn’t change who he is,” she said. “It gave him access to who he already was.”
McCumbee’s experience, which she shared during a North Carolina General Assembly oversight hearing in March, is not uncommon. Families across the state have benefited from ABA in the decade since it was added to the list of services covered by Medicaid, the government-funded health insurance program, and mandated to be covered by many private insurers.
While parents describe the therapy as transformative, recent skyrocketing costs have drawn scrutiny from state lawmakers.
State and federal Medicaid spending on ABA in North Carolina surpassed $505 million in 2025, up from a mere $1.9 million just five years earlier. Costs are projected to exceed $1 billion by 2027, according to the N.C. Department of Health and Human Services.
It is true that autism diagnoses have risen sharply in recent years, in North Carolina and nationwide, as screening has improved and awareness has grown. However, a recent presentation by NC DHHS noted that the surge in spending “far outpaces increases in Autism Spectrum Disorder diagnosis” and cannot “be explained by increased access alone.”
The number of beneficiaries receiving ABA in North Carolina grew from 8,704 people in 2024 to 13,447 in 2025, an increase of about 54 percent. Over the same period, Medicaid spending on the therapy swelled by 65 percent, with the program paying an average of nearly $37,600 per patient last year.
Melanie Bush, deputy secretary of NC Medicaid, said the growth appears to be “concentrated among a small number of providers” — a pattern that has caught the attention of state officials examining who, exactly, is collecting the bulk of North Carolina’s ABA dollars.
The biggest billers
An NC Health News analysis of data from the state health department found that 80 of the more than 200 ABA providers participating in North Carolina’s Medicaid program received at least $1 million in reimbursement for the therapy in 2025. Payments to individual companies ranged as high as almost $65 million.
Nearly half of the providers reviewed by NC Health News were assigned National Provider Identifier numbers in the 2020s, making them relatively recent additions to the federal government’s registry of licensed health care practitioners. In some cases, these newer providers were paid more than established providers operating in the same areas of the state.
Twenty-seven of the providers, or more than a quarter, have out-of-state mailing addresses listed on the registry, indicating their administrative offices are based elsewhere. Of those, five do not have primary or secondary practices — physical or virtual locations where providers are authorized to deliver care under their NPI registration — listed in North Carolina.
Federal rules allow ABA to be delivered through telehealth, meaning a company can serve patients in North Carolina without maintaining a brick-and-mortar presence here.
While studies have shown that telehealth can be an effective vehicle for the therapy, some professionals have questioned whether it is appropriate for all patients. In a presentation to state lawmakers in March, Keith Laabs, CEO of ABA provider Kind Behavioral Health, said “very few of these services can be done over telehealth.”
“If you’ve got a 3-year-old who you’re trying to teach how to communicate, they’re not going to sit in one place,” he said. “If you’re working with a 14-year-old who may have aggression or self injury behaviors, you need to be there in person.”
At the same time, Laabs’ organization, which operates 18 facilities across the state and last year received more than $13.4 million for ABA, has drawn scrutiny for its ties to private equity.
Kind Behavioral Health was among more than a dozen companies singled out in a report published earlier this month by the Private Equity Stakeholder Project. The left-leaning watchdog group found that 15 private equity-backed ABA providers operate more than 130 facilities in the state, making it one of the most saturated markets in the country.
“Private equity firms are using autism therapy as a way to tap into Medicaid dollars,” Ryan Leitner, a health care researcher with PESP, said in a statement. “And what we’re seeing in audits across multiple states is that it’s coming with real problems.
“The same billing issues and oversight failures are showing up again and again, which raises serious concerns about how this care is being delivered.”
Several other providers identified as being backed by private equity in the group’s report were among the businesses that collected the state’s largest Medicaid payments for ABA in 2025. They include:
- Action Behavior Centers, which has 35 facilities in the state and received $2.33 million;
- Centria Healthcare, which has seven facilities in the state and received $2.75 million;
- Autism Learning Partners, which has eight facilities in the state and received $3.76 million;
- ACES ABA, which has two facilities in the state and received $4.25 million;
- Key Autism Services, which has five facilities in the state and received $9 million;
- Hopebridge, which has 13 facilities in the state and received $14.63 million; and
- ABS Kids, a Utah-based company with 11 facilities in North Carolina that received $64.91 million — the most paid to any ABA provider in the state.
To create its analysis of the state’s biggest ABA billers, NC Health News searched through spending data provided by NC DHHS to identify companies that received more than $1 million in Medicaid reimbursement during the state’s 2025 fiscal year. After narrowing our search down to 80 providers, we used the National Provider Identifier registry to determine where those providers are based and how long they’ve been in business. We compiled a spreadsheet of our findings that includes links to each provider’s NPI profile.
Investigations underway
While the totals above do not imply misconduct by any particular provider, officials suspect that some companies are exploiting loose oversight to collect payments for care that was never delivered.
“If you look at the growth in the expenditure for ABA therapy, it deserves to be flagged as a potential source of fraud,” said Jeff Jackson, attorney general for North Carolina.
He added: “We all agree that people who legitimately deserve those services deserve those services, which is all the more reason to go after people committing fraud and draining those resources.”
Jackson, who was responding to a question from state Rep. Allen Chesser (R-Middlesex) during a hearing of the House Select Committee on Oversight and Reform on April 16, revealed that his office is conducting “ongoing investigations into this right now.”
He declined to name the providers under investigation, but confirmed that investigators are looking into improper payments and “phantom billing,” a practice in which providers submit claims for therapy sessions that never took place or bill for more hours than were actually delivered.
“Our adversaries here are just extremely well-funded,” Jackson said. “They have major law firms and they can mount a level of defense that is just orders of magnitude more sophisticated, and I try to be very conscious of that when I’m making public remarks.”
The Attorney General’s Office, he said, has asked NC DHHS to update the section of its Clinical Coverage Policy pertaining to autism with “clearer definitions” of what should or should not be covered by Medicaid — a change Jackson believes will strengthen the state’s ability to prosecute potential cases of fraudulent billing.
“In short, the wording around what some of the requirements are for offering ABA therapy is a little too vague,” he said.
North Carolina is not the only state confronting alleged fraud in autism services. Federal prosecutors in Minnesota last year charged a Minneapolis woman in what they described as the first criminal case tied to a sprawling scheme involving fraudulent autism therapy billing.
According to the U.S. Attorney’s Office, the defendant allegedly used shell companies to bill Minnesota’s Medicaid program for millions of dollars in services that were never provided, then diverted the money for personal use. Prosecutors said the case was part of a broader investigation into misuse of funds intended for children with autism.
Cracking down on costs
The push to rein in spending on ABA has not been without resistance.
In November, the parents of more than 20 children with autism won a temporary court victory in a lawsuit accusing NC DHHS of discrimination after it slashed Medicaid reimbursement rates for the therapy. A Wake County Superior Court judge granted an injunction ordering the department to halt the 10 percent cuts it had imposed on ABA providers amid a standoff over the state budget.
Families argued the rate reductions would delay care their children depended on. In written testimony, Adi Khindaria, CEO of Compleat Kidz — a provider that collected $51.14 million in Medicaid reimbursement for ABA in 2025 — warned that the cuts would double the already six-month wait time for children seeking treatment at his Rocky Mount clinic, and force the elimination of roughly 100 jobs.
Superior Court Judge Clayton Somers sided with the families. In his decision, he noted that NC DHHS, by its own estimates, had sufficient funding to operate through May — making the targeted cuts to ABA providers difficult to justify.
Devdutta Sangvai, head of NC DHHS, has since put forward a sweeping set of proposed revisions to Clinical Coverage Policy 8F — the section of state Medicaid rules governing ABA — that would tighten oversight of providers, restrict the use of telehealth and impose new accountability standards on the therapy’s delivery.
Addressing lawmakers earlier this month, Sangvai said the provisions, many of which are included in a bill that is expected to be voted on soon in the General Assembly, are not meant to limit access to ABA. Rather, they are designed to ensure the therapy reaches the right children in the right way.
“I went to medical school at a time when we were told that autism has no treatment options, and look at where we are today,” Sangvai said. “It’s not [about] whether or not we use it. It’s we have to make sure those services are going exactly to the people who need it in the right amount.”
The draft changes are divided into two phases, with the first round of reforms targeted for implementation by Aug. 1. Among the most significant near-term proposals is a crackdown on telehealth delivery of ABA.
Under the draft policy, providers would be barred from using telehealth for behavioral assessments and individual or group treatment sessions — the services most likely to require direct physical interaction with a child. No more than 10 percent of certain supervisory sessions could be conducted remotely, and providers seeking exceptions would need to submit written justification subject to post-payment review.
The changes would also prohibit out-of-state providers from billing Medicaid unless they operate within 40 miles of the state border, and would require that behavior technicians — the frontline workers delivering most ABA services — obtain national certification.
A second phase of reforms, set up for December, would prohibit providers from diagnosing autism and then referring patients to their own ABA services, a practice that critics say creates a financial incentive to over-diagnose.
Talley Wells, executive director of the North Carolina Council on Developmental Disabilities, expressed support for the proposed changes in an interview with NC Health News, calling them a “step in the right direction.”
“We need to meet the needs of all of our autistic children, and we need to celebrate that so many more autistic children are getting supports and services they need,” he said. “We have to be, on the other side, good stewards of Medicaid, and we have to make sure that we have those guardrails in place to ensure that children are getting what they need.”
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