Billing Max Hours for 80% of Your Clients Is Now a Federal Red Flag

Federal guidance normally describes what good oversight looks like and leaves states to work out the arithmetic. The CMS autism toolkit does something more specific: it tells states to identify providers "billing for the maximum number of hours for 80% or more of their clients."

That is not a principle. It is a query. Any state that acts on it will run it as one, against claims data it already holds, without asking anyone first.

The number behind the guidance

The audits that preceded it have produced a figure. Government audits found nearly $200 million in improper Medicaid payments for ABA services across four states — Indiana, Colorado, Wisconsin, and Maine. Those are the same four completed reports in the HHS Office of Inspector General series, with four more still running.

The spending pattern driving the attention is a divergence rather than a total: ABA expenditures rose 421% between 2021 and 2025, while the number of children receiving the services grew by 67%. Cost per child, not caseload, is what moved. The guidance also names billing for time spent napping and during meals among the practices it wants states to look for.

What being flagged is, and is not

A screen is not a finding. A practice serving a genuinely high-acuity caseload can cross this threshold while every authorization behind it is clinically sound, and a practice under it can still be billing improperly. The ratio identifies who gets looked at, not who was wrong.

That distinction matters because of the order things happen in. The screen runs first. The clinical justification is read afterwards, by someone who already has a reason to be reading it.

What you must know or do

Compute your own ratio this week. Take your active clients, count how many are authorized and billed at the maximum hours their plan allows, and divide. If that number is near or above 80%, you are the profile the guidance describes, whether or not your care is appropriate. Knowing the figure is the difference between preparing an answer and being asked for one.

Check the denominator before you relax. A practice with a narrow referral base — a single school district, one payer, one acuity band — can hit a high ratio without ever intending to. So can a practice that has recently discharged its lower-intensity clients. The ratio moves for reasons that have nothing to do with billing decisions.

Write the rationale now, for the clients at the top of the range. Whichever way the evidence on treatment intensity settles, a contemporaneous clinical justification is what an auditor can accept and a reconstructed one is what an auditor discounts. The screen tells you exactly which files will be pulled first.

Audit the incidental time. Napping and meals are named explicitly. If any part of a billed session covers time that is not delivering a programmed goal, that is the easiest finding in the file and the hardest to argue with afterwards.