Evidence record
Colorado Made at Least $77.8 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children
- Jurisdiction
- Colorado
- Audit organization
- Department of Health and Human Services Office of Inspector General Office of Audit Services
- Publication date
- February 2026
- Source record
- Original document linked
Findings
7
Recommendations
5
Overall conclusion
Colorado’s FFS Medicaid payments for Applied Behavior Analysis provided to children did not fully comply with Federal and State requirements, resulting in improper and potentially improper payments and highlighting a need for stronger governance, oversight, and guidance to prevent future noncompliance.
Scope
Audit covered Colorado's Health First Colorado, the State's Medicaid program, focusing on fee-for-service Medicaid payments for Applied Behavior Analysis (ABA) for calendar years 2022 and 2023. The audit analyzed $289.5 million ($158.2 million Federal share) across 1,057,164 claim lines and 60,131 enrollee-months, with service dates from January 1, 2022 through December 31, 2023 for enrollee-months with payments over $1,000.
Findings (7)
Each finding has a stable link.
- F-1224
All 100 sampled enrollee-months included payments for one or more claim lines that were improper or potentially improper.
- F-1225
Session notes or EVV records did not meet documentation requirements.
- F-1226
ABA was provided by staff who did not have the appropriate credentials.
- F-1227
ABA was provided to children without documentation of a comprehensive diagnostic evaluation or treatment referral for ABA.
- F-1228
The State agency did not perform a statewide postpayment review of ABA payments and did not provide sufficient guidance to ABA facilities.
- F-1229
Oversight of the prior authorization contractor was insufficient to ensure compliance with diagnostic evaluation and referral requirements.
- F-1230
The audit estimated improper payments totaling at least $77.8 million ($42.6 million Federal share) and potentially improper payments totaling $207.4 million ($112.5 million Federal share).
Recommendations (5)
- R-1087
Refund $42.6 million to the Federal Government.
Related finding F-1230 - R-1088
Provide additional guidance to ABA facilities for documenting and billing ABA.
Related finding F-1228 - R-1089
Periodically perform a statewide postpayment review of Medicaid ABA payments to educate providers on requirements.
Related finding F-1228 - R-1090
Strengthen oversight of the prior authorization contractor to ensure that prior authorizations are approved with documentation of required diagnostic evaluations and treatment referrals.
Related finding F-1229 - R-1091
Provide guidance on documentation, credentialing, EVV, and signature requirements; ensure facilities bill only for allowable ABA activities.
Related finding F-1226