Up next for DOJ: Healthcare Fraud in Autism Services
Federal Charges Alleging Autism-Services Fraud in the District of Minnesota
In Minnesota, autism-services fraud has moved from rumor to charges. On September 24, 2025, federal prosecutors from the United States Attorney’s Office for the District of Minnesota filed the first case tied to alleged abuse of the state’s Early Intensive Developmental and Behavioral Intervention (“EIDBI”) program, which funds medical services for people under the age of 21 with autism-spectrum disorder. That case involved charges against a single defendant who operated a Minneapolis clinic and received Medicaid funds under the EIDBI program. That defendant, according to the filed Information, allegedly ran a $14 million scheme that involved billing for services not provided, upcoding of medical services, and paying kickbacks to the families of patients. Expect additional cases in this area to come down the pike in the next six months.
Overview of Autism-Fraud Cases
“Autism fraud” is not a criminal offense. It is instead a general label for different billing and medical documentation issues, all of which can be packaged up by prosecutors to allege fraud on a federal program, usually Medicaid. Federal investigations into “autism fraud” are often run by United States Attorney’s Offices (USAOs), the Fraud Section of DOJ’s Criminal Division or both. These cases are investigated by HHS-OIG, the FBI, CMS contractors (UPIC/ZPIC) or state Medicaid Fraud Control Units (MFCUs). Such personnel often either work in parallel with each other or jointly to investigate a case.
Autism fraud cases are similar to general healthcare fraud cases and exhibit common allegations, which include:
• Services not rendered or inflated time: The claim says 60 minutes of services; the visit lasted 5 minutes or not at all
• Upcoding: Billing one-to-one codes for group services or higher-paying codes without medical necessity
• Unqualified staff or missing supervision: Claiming medical services were provided by a qualified medical professional when they were not
• Telehealth/modifier/Place-of-Service errors: Billing tele-supervision as direct, in-person therapy
• Kickbacks: Paying patients (or patient’s families) to receive medical services from a certain provider
These cases, like all healthcare fraud cases, will turn on challenging the government’s proof as the critical intent element: willful intent to defraud.
The Types of Conduct Investigated in Autism-Fraud Cases
The following provides more detail on the types of conduct that are often alleged in federal healthcare indictments and will be likely alleged in autism fraud cases going forward.
Services Not Provided
Services not rendered: Claiming payment for medical services that did not occur.
Upcoding: Using 1:1 codes for group therapy or selecting higher-paying codes without documented medical necessity.
Kickbacks and Unlawful Inducements
Kickbacks: Providing patients or the patient’s families cash, gift cards or perks so that the beneficiary will agree to receive medical services from a certain provider.
“Marketer” payments: Paying third-party recruiters to sign up beneficiaries for medical services.
Medical Necessity Issues
One-size-fits-all hours: Billing every patient for the same treatment without individualized assessment and patient plan.
Progress not tracked: Maintaining medical records that have goals for patients that never change and have no basis for justifying the claimed services.
Documentation & Records Integrity
Cloned or templated notes: Using identical patient notes and treatment narratives across patients or auto-generating text that lacks patient-specific detail.
Backdating / altered records: Modifying patient files following a request for medical records or bulk creating medical records after a similar request for patient files.
Missing corroboration: Absence of backup documentation, such as sign-in/out forms or administrative paperwork to prove the claimed medical services.
Credentialing, Supervision & Scope-of-Practice
Non-existent credentials: Claiming that medical services are provided by a licensed medical professional when the services are actually provided by an unlicensed employee.
Telehealth, Modifiers & Place-of-Service
Modifier misuse: Billing tele-supervision as direct, in-person therapy.
Location mismatches: Records say home-based treatment, but GPS/payroll show clinic—or vice versa.
Documentation issues: The patient files do not support the claimed medical service.
Identity & Enrollment Issues
NPI misuse: Billing under a clinician who wasn’t involved in the claims medical services or cycling through various NPIs for specific medical services in an effort to avoid detection.
Phantom providers: Claiming medical services on behalf of a medical professional who is no longer associated with an entity.
Patient identity errors: Wrong beneficiary IDs; templates pulling the wrong child’s details.
“Double Dipping”
Double billing: Charging Medicaid for services already reimbursed by schools or grants.
Obstruction, False Statements & Post-Notice Conduct
Obstruction: Shredding paper logs or deleting EHR audit trails or chats after receipt of a request for information, such as a subpoena for medical records.
False Statements: Intentionally and willfully providing to federal law enforcement false information about whatever conduct is investigated.
How Federal Investigations of Autism-Services Fraud Unfold
For a more in-depth explanation of a federal healthcare investigation, please see the earlier post here. The following hits the highlights of any federal healthcare investigation, including an investigation into autism fraud.
What starts an investigation
· Data analytics flag outliers (impossible hours, overlapping staff, weekend spikes in services).
· Tips/whistleblowers from employees or associated individuals or parent complaints.
Early evidence collection (civil/administrative and criminal)
Record demands from CMS contractors (UPIC/ZPIC/SMRC) or Medicaid Fraud Control Unit (MFCU).
Civil Investigative Demands (CIDs) in False Claims Act probes.
HHS-OIG subpoenas.
Grand jury subpoenas.
Search warrants: electronic devices and electronic medical records (EHRs)
Interviews of parents, employees, schedulers, and billers.
Forensic examination: EHR audit trails, geolocation analysis, payroll vs. billed units.
Parallel tracks & outcomes
Civil FCA (filed under seal), administrative recoupment, and criminal referrals.
Outcomes range from FCA settlement, criminal charges or both.
Common Criminal Charges in Autism-Fraud Cases
For a more fulsome explanation of a commonly charged federal statutes in a healthcare investigation, please see our earlier post here. The following details the most commonly charged offenses in this context:
Health Care Fraud (18 U.S.C. § 1347): A knowing, willful scheme to defraud a health-care program (Medicaid).
Wire/Mail Fraud (18 U.S.C. §§ 1343, 1341): Using email or mail to carry out the scheme.
Conspiracy (18 U.S.C. §§ 371, 1349): Agreement to commit an underlying federal offense.
False Statements in Health Care (18 U.S.C. § 1035): Materially false statements in health-care matters.
Substantive Violations of the Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)): Paying or receiving anything of value to induce referrals for medical services payable by a federal healthcare program.
Aggravated Identity Theft (18 U.S.C. § 1028A): Using a beneficiary’s identity during certain felonies.
Money Laundering (18 U.S.C. §§ 1956, 1957): Moving or spending proceeds to conceal or promote the scheme.
Defending an Autism-Fraud Case
Undercutting absence of wrongful intent and proving good faith: Collecting evidence of compliance training, policies, internal audits, outside counsel review, and fast remediation when issues surface.
Highlighting sound clinical judgment and medical necessity: Explaining why the child needed the intensity, setting, and duration of the at-issue medical services, all of which should be supported in contemporaneous medical documents.
Proving compliance with relevant rules: researching and analyzing the correct at-issue codes and modifies, including whether those codes changed over time, to highlight ambiguity or “grey areas” in the rule’s requirements.
Rebuilding reality with data: Lining up payroll, GPS, school calendars, caseloads, travel time, and supervision logs so the alleged numbers make sense.
Proving proper supervision & licensure: Keeping accurate records of credentials, medical supervision, and appropriate roles for various employees.
Proving AKS safe harbors: Uncovering evidence that disproves the government’s theory of referral-tied remuneration and instead shows fair-market value services, among other things.
Attacking the investigation: Challenging warrants and exploiting mistakes in the investigation and “fact” gathering.
Conclusion
Federal autism fraud cases will increase around the country. DOJ builds these cases in largely the same way as traditional healthcare fraud cases by focusing on the data, identifying problematic patterns, identifying any falsified medical documents, and seeking to identify evidence that proves wrongful intent by one or more individuals. The charging tools (healthcare fraud, wire or mail fraud, false statements, violations of the Anti-Kickback Statutes, and civil FCA) are serious. But these cases are defensible, given the complexity in the area and the difficulty the government has in proving wrongful intent.
Need help? Contact Scott Armstrong, an experienced healthcare fraud attorney. Scott is a defense attorney for medical professionals in federal healthcare cases involving healthcare fraud and violations of the Anti-Kickback Statute. To defend individuals in these cases, Scott relies on his litigation experience in Miami, Chicago, Houston, Denver, DC, Alexandria, Newark, Nashville, Knoxville, Detroit, Columbus, Los Angeles, and New York.
