This is an exclusive BHB+ story

Out-of-network billing is almost unheard of in autism therapy — a stark outlier in behavioral health where such practices are common.

Out-of-network billing for applied behavior analysis (ABA), the core therapy of the industry, accounts for mid- to low-single digits of health care spending in some estimations across any given plan. In some cases, out-of-network spending is limited to markets where a health plan has struggled to meet local surges in demand or is used as a stopgap measure for temporary contracting or coverage issues.

This makes the intentional use of out-of-network billing exceptional in the industry. What’s more, the increased costs several payers have experienced in 2025 make it likely health plans are going to take an even more skeptical approach to out-of-network billing.

The large managed care organization Centene Corp. (NYSE: CNC) specifically cited elevated autism therapy costs as a driver of “unanticipated” and “unacceptable” levels of reimbursement spending earlier in the year.

“It’s not a big secret that there is open skepticism about ABA from payers,” Nick James, chief development officer and chief financial officer for New York City-based Autism Care Partners, told Behavioral Health Business. “We’ve seen [several] health plans pull their guidance for the year, with some of them specifically referencing ABA as a key driver along with oncology, kidney care and other chronic conditions. If I’m putting my health plan hat on, it makes sense why [plans] would be much more prudent, or call it stringent, on what is allowed when it comes to out-of-network providers.”

James joined Autism Care Partners, a multi-specialty autism therapy provider operating in five Northeastern states, after a more-than-decade-long career in the health plans space, which included work with specialty populations.

At his organization, Autism Care Partners’ out-of-network billing, including single-case agreements, is less than 10%. This often includes secondary billing when a patient has coverage from multiple plans and the secondary plan happens to be out of network.

Many providers point to accessibility and affordability for patients as the key motivators for opting to focus on in-network billing. ABA can be pricey and intensive therapy that requires most patients and families to have a third party help cover costs. Additionally, a previous successful movement at the state level to institute specific legislation or other rules mandating the coverage of autism therapy has created a system where in-network billing accounts for nearly all claims.

James and others note that the industry is still relatively new. They say that out-of-network billing as an intentional strategy was once more common but is all but abandoned today.

“There has absolutely been a pendulum swing,” James added.

While other organizations may be engaged in out-of-network billing as a core strategy, few have done so and garnered as much attention for their growth as Fort Lauderdale, Florida-based ABA Centers of America.

Previously, ABA Centers of America’s founder and now-Chairman Christopher Barett told BHB that the company uses proprietary business intelligence software to identify underserved markets and establish single-case agreements and bill area plans on an out-of-network basis. This strategy has led to remarkable financial growth and gives it what Barnett said was an ability to better train and pay employees higher wages than the market norm.

ABA Centers of America has been the highest-ranking behavioral health company on the Inc. 5000 list of the fastest-growing American companies over the last two years. For the 2025 list, it landed at No. 25 with a three-year revenue increase ending in 2024 of 7,755%. Its revenue is in the range of $250 million and $500 million.

The company’s billing practices have landed it in court. 

A representative of ABA Centers of America did not return a request for comment for this article.

Payers’ and providers’ dislike of intentional out-of-network billing

Generally, provider and payer executives don’t see intentional out-of-network billing in the autism therapy space as appropriate for the long-term success of the industry. In previous reporting, sustained out-of-network billing practices were identified as a deal killer in the space.

Some go so far as to say the practice is exploitative.

“[Some providers] will force the hand of the health plan by saying, ‘If you don’t have any network providers, you have to give us this authorization. And if you can’t find a network provider with a timeframe, you’ve got to give it to us, and, oh, here is our rate. Too bad, so sad,'” Yagnesh Vadgama, vice president of clinical care for autism at Magellan Health, told BHB. “They know what they are doing.”

Depending on the state, health plans are required to help members find available in-network clinicians within 10 to 15 business days. Otherwise, the member is typically allowed to use their in-network benefits and cost-share obligations even for providers that aren’t in network.

Such practices can limit a health plan’s ability to increase pay rates for in-network providers, Vadgama said. Health plans have limited annual budgets for spending and rate increases. Out-of-network payments require a disproportionate amount of funding.

James said the practice throws the payer-provider dynamic out of balance within a given market.

“Quite frankly, it can disenfranchise other providers by setting a price that is just unsustainable in terms of how payers are looking at holistic cost utilization within a cohort of hundreds of providers,” James said.

Vadgama said there are valid and meaningful uses of out-of-network billing and single-case agreements. Often, they revolve around the severity or uniqueness of a member’s health needs and the relative availability within a market. He gave the example of a unique instance where a member with autism also had a severe eating disorder in New Mexico. Magellan Health authorized out-of-network treatment for a provider in Kansas.

“There’s nobody in New Mexico who could do it,” Vadgama said. “We happily gave that out-of-network authorization to that provider so that member could go out there and seek treatment.”

Another application of single-case agreements and out-of-network billing applies to smaller and more geographically diffuse membership bases, Vadgama said. He cited the example of the benefits Magellan Health offers to a union whose members are spread across the U.S. and beneficiaries total about 100.

In a large plan managed by Magellan Health, only 1.2% of utilization during the first quarter occurred on an out-of-network basis.

“That’s tiny,” Vadgama said.

In other cases, new providers joining a network that are still working through a credentialing process could temporarily get a single-case agreement. In limited circumstances, James noted that Autism Care Partners will establish out-of-network or single-case agreements when a patient is changing health plans or when a protracted payer negotiation is ongoing.

Autism therapy likely to remain unlike the rest of behavioral health 

Several studies highlight the much higher rate at which mental health and addiction treatment are accessed on an out-of-network basis relative to physical health care. This is frequently seen as a failing of parity enforcement. One study found that patients go out of network for behavioral health 3.5 times more often than other types of care. The same study found that, on average, behavioral health providers are paid 22% less than comparable physical health care providers.

Access challenges persist in the autism therapy industry. However, it has more to do with the industry’s ability to generate clinical staffing commensurate with the level of demand in a given market, as opposed to coverage through a health plan, following a decade of massive investments from private equity and others to expand access to services.

“It’s very easy to find in-network ABA providers; there are ABA providers everywhere now,” Vadgama, who started his career as a BCBA, said. “There’s absolutely more access today. The industry is more robust now than it ever has been.”

Where there are challenges in increasing access, it has more to do with cooperation between health plans and providers to match availability with patient demand, Vadgama added. 

A more collaborative stance between providers and payers is often cited as a key component for future innovation and expansion within autism therapy. What’s more, it would be tremendously difficult and risky for providers to pursue out-of-network billing like other segments of behavioral health.

“If I’m a provider, single-case agreements and the like are more work because they are outside of the typical process flow, and it affects everything within an organization,” Rick Loewenstein, CEO of TeamGame Advisors, an autism therapy advising organization, told BHB. “Anything that’s out of a typical process flow within an organization is an area of potential exposure.”

Part of the exposure comes from these types of billing arrangements being outside the typical payer workflow. It creates uncertainty around the timeliness of reimbursement, security of the claim itself, and open questions regarding the quality of care.

These approaches also foster a transactional relationship between payers and providers.

“There’s an opportunity for providers to build that relationship to help solve problems, share data, identify gaps in services and address problems with families,” Loewenstein said. He added that with a heavy focus on out-of-network billing, “you don’t get any of that and you’re not able to build long-term relationships. I don’t think that is a sustainable strategy.” 

Other segments of behavioral health that were once heavily reliant on out-of-network billing have been struggling. Specifically, out-of-network luxury addiction treatment has faded significantly since the mid-2010s, as payers have largely shut off high payment rates in favor of less expensive care settings and lower-intensity care types, and the investment segment has balked at that shift in payer appetite.