When Systems Fail Quietly: Optum, Medicare Fraud, and the ABA Fallout We Can’t Ignore
In late May 2025, the headlines broke wide open: UnitedHealth Group and its subsidiary Optum were under federal investigation for alleged Medicare fraud. According to whistleblower reports and coverage from outlets like HIT Consultant , the U.S. Department of Justice has launched a criminal probe into whether UnitedHealth knowingly submitted inflated risk adjustment scores to secure higher Medicare Advantage payments.
As shocking as that sounds, the details were more troubling. Investigators are reportedly examining a pattern of submitting unsupported diagnoses—potentially earning the insurer billions in improper...
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reimbursements. This follows a series of investigative reports alleging secret financial arrangements with nursing homes to minimize costly hospital transfers for Medicare Advantage members, raising concerns about how patient care may have been influenced by cost-saving objectives.
From a national standpoint, these events may feel distant. But for providers in the ABA community, there’s a growing sense that these headlines aren’t just about some other part of the system. They’re hitting much closer to home.
The Letters Are Arriving
Over the past year, a number of ABA practices—across multiple states—have reported receiving letters from Optum or UnitedHealthcare notifying them of contract terminations. These are not termination-for-cause notices related to a specific compliance issue. Instead, they cite standard “without cause” clauses that allow either party to exit the agreement with 90 days’ written notice.
And that’s it. No explanation. No cited deficiencies. Just a date, a legal reference, and a customer service number.
The scope of these terminations is still unclear. They are anecdotal and dispersed. But the stories are increasing in frequency and share a striking similarity: providers are caught off guard, confused about what happened, and left without any clear next step.
Some have reported that they were under audit or had been asked to submit clinical documentation weeks or months earlier—but with no indication that termination was imminent. Others say they had no active compliance issues at all. In many cases, efforts to follow up with network managers or provider services have been met with silence, long delays, or vague reassurances that don’t answer the central question: why?
An Ethical Gray Zone: 'Without Cause' in Practice
Every payer contract includes a termination clause. This is standard legal practice. The “without cause” clause exists to protect both the payer and the provider from long-term entanglements if the relationship no longer makes sense.
But when that clause becomes a tool of opacity—used to remove providers with no discussion, no resolution process, and no accountability—it begins to feel less like a contract safeguard and more like an eject button.
That leaves providers in a deeply vulnerable position:
- Clients face care disruption.
- Staff must shift hours or caseloads quickly.
- Revenue may drop dramatically.
- And the provider is left with no path to resolution—just a deadline.
In a system where ethics are supposed to matter, this isn’t just inconvenient. It’s demoralizing.
What Does This Have to Do With the Medicare Fraud Allegations?
Here’s where it gets complicated—and where we need to tread carefully.
There is currently no public evidence that these contract terminations are directly tied to the DOJ investigation. No documentation links ABA contract reviews to the Medicare Advantage billing scandal. No names, dates, or internal memos have surfaced tying the two events together.
So, we’re not going to make that leap.
What we can do, however, is recognize a broader pattern. Because taken together—the fraud allegations, the abrupt terminations, the unexplained audits, the cyberattack on Change Healthcare (another UnitedHealth subsidiary), and the wave of billing disruptions across the country—what we’re seeing is a system under extreme operational stress .
And when large systems come under strain, it’s not the executive teams that feel it first. It’s the providers. The small businesses. The clients. The people.
The Ransomware Attack That Still Lingers
In early 2024, a massive cyberattack compromised Change Healthcare’s systems—an entity owned by Optum that handles claim processing for millions of providers, including ABA clinics. The result was catastrophic: widespread claim delays, disrupted pharmacy services, and confusion across the healthcare system about what data was accessed and who might be at risk.
The incident added a new layer of operational disruption at a time when providers were already managing complex billing environments and strained payer relationships.
An Unequal Burden on Providers
When any systems fails—whether through fraud, technical breakdown, or administrative neglect—it’s rarely the system that pays the price. It’s the providers. The ones who:
- Send appeals that never get answered.
- Try to call network managers who won’t respond.
- Spend hours recredentialing with clearinghouses that lost their data.
- Have to explain to families that services are ending, not because of a clinical issue, but because the business relationship was severed in a one-paragraph letter.
And most painfully, it’s the clients who suffer the real consequences. Especially those relying on Medicaid.
For some families, Optum manages their Medicaid-funded ABA coverage through contracts with state agencies. Losing that access—suddenly, with no warning—can mean losing services entirely. These are not just billing headaches. They are disruptions in care for vulnerable children. These are breaks in trust between families and providers.
How the ABA Community Is Responding
Right now, the response is fragmented. Some providers are:
- Messaging Optum on social media to try and escalate communication.
- Contacting state Medicaid agencies directly to confirm whether their plan participation is affected.
- Digging through contracts to understand their rights.
- Reaching out to professional communities for help navigating the unknown.
What’s consistent across the board is that no one feels like they’re getting clear answers . And that is where the real concern lies.
What Should ABA Providers Do Now?
If you’re reading this and wondering whether you’re at risk, here are a few things we suggest—based not on fear, but on preparation:
- Review your payer contracts, especially termination clauses.
- Back up your documentation—especially audit-related materials.
- Maintain open communication with families about potential changes.
- Confirm Medicaid participation status with state agencies if applicable.
- Seek legal advice if termination impacts a significant portion of revenue.
- Connect with peers to share information and support.
Let’s Talk About Ethics
As ABA professionals, we often talk about ethics in terms of clinical decision-making. But system-level ethics matter too.
When large corporations use vague legal clauses to end care relationships without warning, we have to ask: Is this how ethical healthcare operates?
When providers are left without recourse, and clients without continuity, is this acceptable simply because the contract allows it?
When billions of taxpayer dollars flow into Medicare Advantage plans under scrutiny for fraud—and providers are still waiting months to get paid, or scrambling to protect their clients from the fallout—something is broken.
And we have an obligation to speak that truth. Calmly. Clearly. Professionally. But unapologetically.
Final Thoughts: This Is Bigger Than ABA
This isn’t just an ABA problem. It’s a healthcare system problem.
When efficiency, profit, and opacity are prioritized over clarity, ethics, and humanity—everyone suffers.
So while we wait for investigations to play out, while we navigate audits and denials and sudden contract changes, let’s keep our eyes on the reason we’re here in the first place:
To help people. To support families. To deliver quality care.
We may not be able to fix the system alone. But we can hold the line. And we can hold each other up.
