I have often argued that health care has turned into a Gold Rush, where bad actors are allowed to price gouge with impunity. Any complaints are dismissed as “that’s just how it is in health care.” Lawyers for hospitals and other providers spend years perfecting financial responsibility contracts that patients are supposed to sign with little legal knowledge, or legal representation. Mutual assent in health care – a meeting of the minds necessary for an enforceable contract in other areas of the economy – consists of handing someone a form they do not have time to read.
I have written about numerous examples of abuse over the years. From anesthesiologist-owned lab that charged a Texas woman $17,850 dollars for urine drug screen that should have lost less than $100; to a Florida woman charged 15,242 for preventive injections in case she was exposed to rabies, 10 times what other facilities charged. There was the New York man whose assistant surgeon charged $117,000 for a service that Medicare would only have paid $850. Then there are air ambulance rides that cost $1,000 a mile. A Colorado woman was erroneously told her copay would be $1.337 but was later hit with a $230,000 surprise bill. When a jury said she did not owe it an appeals court ruled in favor of the hospital. There are examples of doctors charging hundreds to remove a splinter, claiming it meets the criteria of surgery. Some private equity-owned facilities charge double when a colonoscopy requires polyp removal. These examples are exceptional only in how common they are.
Services like autism coverage are mandated in health plans. Yet, nothing is done when unscrupulous providers take advantage of the mandate. I recently wrote about the autism fraud preying on state Medicaid programs. It first became known in Minnesota, where unscrupulous providers billed for services not rendered. (These people will go to jail) A New York Times investigation found some (more legitimate) providers billed for excessive therapy, often 40-hour weeks of therapy for pre-school children that was of questionable benefit. A Wall Street investigation found similar abuse, saying:
The autism-therapy industry, once a tiny corner of pediatric care, has exploded into a multibillion-dollar business, fueled by rising diagnoses, new providers entering the market and laws requiring insurers to cover more services. It has also attracted predatory providers who bill for phantom services, pad hours and charge steep fees for care delivered by low-wage workers with minimal training.
The billing abuses run wide. Aetna said the number of investigations that found likely fraud or abusive billing by autism-therapy providers in its private-plan business shot up by 300% between 2024 and 2025—and is on track to rise by another 50% this year.
The issues detected by the insurer’s probes include poor documentation, billing for multiple services for the same hour and claiming to provide care at home addresses that don’t really exist, said Katerina Guerraz, Aetna’s chief operating officer.
WSJ reviewed a bill that included a daily charge for one child that exceeded $30,000. The WSJ had several takeaways from its investigation:
The workforce is surging. Numerous providers are joining the ranks. In the past six years the number of behavioral technicians registered in the federal database of health care providers has risen 457%. There appears to be few rules about who is allowed to provide care or what training is necessary.
Questionable billing practices. While some autism treatment firms pushed parents to enroll their kids in excessive hours of therapy, a firm WSJ investigated charged prices that were far beyond reasonable.
Prices are high. In one case WSJ found a firm billed $436 a minute. When the insurer balked at paying the firm went after the child’s parents for payment. One provider in Brooklyn created more than 100 limited liability companies to obscure how much his one company was billing for services.
Fraud and abuse is rampant. Therapy sessions can cost anywhere from $60 an hour to $13,000 an hour in one example – 150 times the in-network rates. Therapists are often young people with no formal training, paid only $15 to $20 an hour rather than people with master’s degrees and specialized training. Therapy consists of everyday tasks, chores or playing with educational toys or puzzles.
Perhaps the biggest takeaway from the WSJ investigation was that this problem is not going away anytime soon. No parent would pay hundreds per hour, thousands per day for care of marginal benefit. However, when someone else is paying the bill unscrupulous vendors swoop in to loot the store.
Read more at WSJ: The Autism-Therapy Business Is Booming—and So Is the Billing Abuse
WSJ: Five Takeaways From the WSJ’s Autism Billing-Abuse Investigation