Federal prosecutors and auditors are targeting Medicaid behavioral health fraud on multiple fronts, with billions in alleged false claims under scrutiny nationally and two states alone facing audit findings of more than $123 million combined in potentially improper payments for autism and other services.
The enforcement wave — spanning methadone clinics, autism centers, psychiatric hospitals and community behavioral health organizations — reflects a sharp increase in oversight of a sector that expanded rapidly post-pandemic.
Here are seven things to know with respect to fraud cases and audit findings:
1. Daniel Robinson, CEO of Oak Lawn, Ill.-based ODA Solutions, a methadone clinic, was charged with one count of healthcare fraud and one count of money laundering in connection with what the Justice Department described as a scheme to defraud the Illinois Medicaid program.
Prosecutors accused Mr. Robinson of directing others to create fake medical records and bill Medicaid for counseling services that were not provided, including for beneficiaries who had died, in January 2024.
The charges are part of the department’s 2026 National Healthcare Fraud Takedown, which is addressing over $6.5 billion in alleged false claims and patient harm and deaths.
2. Four people were charged in federal court in Ohio in what authorities described as a $30 million fraud conspiracy involving billing for children’s behavioral health services that were not provided.
Two defendants owned and operated behavioral health service organizations, claiming to provide therapeutic behavioral services and psychotherapy to children and young adults attending summer camps, church groups and recreational programs. The defendants are accused of conspiring to “submit false and fraudulent claims for services that were medically unnecessary and not provided as represented.”
3. The Justice Department charged two individuals in connection with an approximately $46.6 million scheme to defraud a publicly funded Minnesota healthcare program that provides medically necessary services to individuals younger than 21 with autism spectrum disorder.
The department charged the defendants with paying “kickbacks to parents who brought their children to autism centers, diagnosed children with autism regardless of medical necessity and billed for autism services that were not provided.”
4. Tampa, Fla.-based Oglethorpe — an operator of psychiatric hospitals — and three of its executives agreed to pay $32 million to resolve allegations they violated the False Claims Act by failing to return Medicare overpayments tied to psychiatric admissions at three Ohio facilities.
The settlement resolves allegations against Oglethorpe, founder and principal owner Robert Cohen, CEO John Picciano and COO James O’Shea. According to allegations detailed in a May 27 Justice Department release, from 2021 through the present, the defendants knowingly failed to return overpayments identified by the company’s consultants.
5. Quincy, Mass.-based Nova Psychiatric Services, Philadelphia-based Patriot Eldercare and psychiatrist Alexandra Accardi, MD, agreed to pay $1.4 million to resolve allegations they fraudulently billed Medicare, Medicaid and the Massachusetts Group Insurance Commission for psychotherapy and medication management services that were not performed.
Nova and Patriot, collectively known as Prime Behavioral Health, operate behavioral health clinics in Quincy and Weymouth, Mass. Dr. Accardi is the founder and owner of both organizations.
Federal officials alleged that between Jan. 1, 2017, and May 18, 2023, Nova and Patriot submitted claims for services behavioral health clinicians did not provide. The Justice Department said Miguel Saravia, Nova’s COO, directed independent contractors to alter claims before submission by adding billing codes for psychotherapy and medication management services that clinicians had not performed.
6. According to HHS’ Office of Inspector General, Colorado’s fee-for-service Medicaid payments for applied behavior analysis did not fully comply with federal and state requirements, estimating $77.8 million in improper payments.
The OIG audited 2022 and 2023 payments, examining whether the state’s fee-for-service Medicaid payments complied with federal and state requirements, and found that all 100 sampled enrollee-months included payments for one or more claim lines that were improper or potentially improper.
7. In January, an OIG report reviewing Maine’s 2023 fee-for-service Medicaid claims for rehabilitative and community support services estimated $45.6 million in improper Medicaid payments for services intended for children with autism.
Common issues included missing comprehensive assessment or those lacking required signatures (81 enrollee-months), session notes that did not meet documentation requirements (64), treatment plans without parent or guardian signatures (30) and missing provider credentials (20), according to the report.
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