What families should know when private clinics evaluate and also sell ABA
Autism diagnoses are up, access is still uneven, and most providers are doing their best. But when the same company that evaluates your child also sells long-term therapy, there’s a built-in conflict of interest families should handle with extra care. Below I break down the facts, the ethics, and the steps you can take to protect your child and your wallet.
The facts: prevalence is rising...and that’s complicated
The CDC’s latest surveillance report estimates 1 in 31 U.S. 8-year-olds are identified with autism (3.2%), up from 1 in 36 in the prior cycle. That jump reflects better awareness and screening—but also differences in local practices and systems.
Researchers have shown that part of the long-term increase is explained by diagnostic substitution (children who might previously have received other labels now receiving ASD) and changes in criteria over time. That’s not “fake autism”—it’s a reminder that context and methods affect who gets diagnosed.
Telehealth and rapid-access clinics have also experienced rapid growth. Many do careful work and can shorten long waits; early studies suggest remote assessments can be feasible, but accuracy and “diagnostic certainty” vary across programs and populations. Families should ask hard questions about the process, tools, and clinician credentials.
Who should diagnose autism?
The American Academy of Pediatrics (AAP) recommends universal screening at 18 and 24 months and referral for a comprehensive evaluation when concerns arise. Qualified diagnosticians typically include developmental-behavioral pediatricians, child psychologists/neuropsychologists, child psychiatrists, and pediatric neurologists. Primary-care pediatricians can sometimes complete the diagnosis when properly trained and using validated tools. Board-Certified Behavior Analysts (BCBAs) do not diagnose; their role is assessment for treatment after a diagnosis is established.
Where overdiagnosis could creep in
Most clinicians act ethically. Still, three system-level pressures can skew decisions:
Financial conflicts of interest (COIs). When evaluators are employed by, or closely tied to, ABA providers, they benefit when more children qualify for intensive services. A 2021 review found pervasive, often undisclosed COIs in autism intervention literature, underscoring why transparency matters.
Coverage rules + market growth. Every state now mandates some level of autism coverage, and ABA is frequently reimbursed once an ASD diagnosis exists. That has fueled rapid sector expansion—and, at times, aggressive business practices.
Fraud and billing risk (industry-wide). Government watchdogs have flagged improper Medicaid payments for ABA and, in some cases, fraudulent billing by providers—reminders that oversight varies and families should review claims and treatment logs. (Fraud cases don’t equate to overdiagnosis, but they demonstrate that financial incentives can distort care.)
Ethics that should protect you (and how to use them)
The BACB Ethics Code binds behavior analysts to avoid conflicts of interest, be transparent about third-party payors, and prioritize client welfare. That means clear boundaries between diagnosis and treatment planning, informed consent, and data-driven care. Ask providers how they operationalize these standards in your child’s case.
Insurers often require that the diagnosis be provided by an independent, qualified health professional (such as a physician or licensed psychologist) and that a separate practitioner (e.g., a BCBA) develop the ABA plan. If one company is doing both, request documentation of safeguards to mitigate COIs.
A family checklist to reduce the risk of overdiagnosis
Confirm credentials. Who will diagnose: a pediatric psychologist, developmental pediatrician, psychiatrist, or neurologist? Obtain names, licenses, and specialty training information upfront. (BCBAs do treatment planning, not diagnostic determinations.)
Ask about tools & time. Will they use gold-standard instruments (e.g., ADOS-2/ADI-R) along with a comprehensive developmental history? How many hours and how many informants (parents/teachers) are included? One brief play session shouldn’t be the sole basis.
Separate diagnosis from sales. If the evaluating clinic also sells ABA, ask for an independent second opinion or choose an outside diagnostician. Document how the clinic prevents COIs (e.g., salary—not volume—based incentives).
Request your data. Keep copies of reports, score sheets, and videos used in telehealth evaluations. If the result is “ASD,” ask what differential diagnoses were ruled out (language disorder, ADHD, intellectual disability, anxiety, trauma).
Check payer rules. Verify your insurer’s diagnostic/authorization criteria and whether an independent diagnosis is required for ABA.
Monitor necessity & progress. For ABA to remain medically necessary, goals must be individualized, clinically significant, and show progress with data; otherwise, dosage should be adjusted. Fraud alerts in the sector make vigilant record-keeping wise.
What about screening tools that flag “autistic traits”?
Screening is not a diagnosis. Studies show standard screens can over- or under-flag children; comprehensive evaluations still matter. If a clinic wants to move directly from a brief screen to long-term therapy without a thorough assessment, slow down and request an independent review.
Bottom line
Autism identification has improved, but rates vary across communities and methods.
Ethical practice separates diagnosis from the business of selling therapy—or, at a minimum, makes conflicts explicit and manageable.
Families can—and should—ask pointed questions, request independent evaluations, and require data-driven justification for any intensive plan.
Sources & further reading
CDC ADDM Network (2025): U.S. prevalence now 1 in 31 among 8-year-olds; methodology and site variability. CDC+2
Diagnostic drivers: Reviews on diagnostic substitution/criteria shifts and misdiagnosis challenges. PMC+1
Who can diagnose? AAP guidance; APA patient guidance; PCP reliability study. Pediatrics PublicationsAmerican Psychiatric AssociationPMC
COIs in autism intervention research: Bottema-Beutel et al., 2021 (Frontiers; PubMed/PMC). FrontiersPMCPubMed
Ethics: BACB Ethics Code for Behavior Analysts (current code PDF). Behavior Analyst Certification Board
Insurance & separation of roles: UnitedHealthcare ABA clinical policy: diagnosis by physician/psychologist; treatment plan by BCBA. Provider Express
System integrity/fraud context: OIG improper ABA payments (WI 2025; IN 2024); DOJ/AG settlements and press releases. Office of Inspector General+1Department of Justice+1Mass.gov
Telehealth diagnosis evidence (mixed but promising with caveats): Systematic/scoping reviews and clinical studies. PMCBioMed CentralACAMH
This article provides general information and advocacy tips. It is not medical or legal advice. Families should consult qualified health professionals for diagnosis and individualized care.
