A former autism center employee tried to report fraud to the state. Nobody responded.

Smart Therapy Center is an autism center housed inside this building on Nicollet Avenue in Minneapolis. Photo by Max Nesterak/Minnesota Reformer.

A former supervisor at a Minneapolis autism therapy provider called Smart Therapy Center made repeated attempts to report what she said were negligence and fraud to state officials.

The woman, who was granted anonymity because she fears retribution for speaking out, said she worked at the autism center for almost two years.

“Clients aren’t learning anything from this agency. This agency will do anything to keep clients from going to other centers to seek the additional assistance they require or need,” she wrote in an email to the state Department of Human Services.

The former Smart Therapy worker’s account offers clues as to why and how federal investigators are examining potential Medicaid fraud in the state autism program, as the Reformer first reported in June.

Minnesota doesn’t license autism centers, so there’s virtually no regulatory oversight. A federal investigation of a fraud-riddled federal child nutrition program unearthed connections to Minnesota autism centers, which have exploded in growth since 2018. The number of autism therapy providers increased 700% in the past five years, while payments to providers increased a whopping 3,000%.

Smart Therapy Center hires relatives or young people with no education or experience so they can pay them less and conceal their activities, the former worker said.

“I and other former employees witnessed some neglect regarding clients’ education needs and self-care. The clients’ goals aren’t being run by the behavioral therapist there,” she told DHS, which administers Minnesota’s version of Medicaid, known here as Medical Assistance, a federal-state health plan for poor and disabled people.

Smart Therapy did not respond to a request for comment.

The state is investigating 15 autism providers, has already withheld payments to providers and forwarded five to Minnesota Attorney General Keith Ellison. Although the identities of the centers are unknown, an immigrant autism provider complained that DHS discriminates against minority providers.

The autism investigation comes close on the heels of the Feeding Our Future scandal, which is believed to be the biggest pandemic relief fraud in the nation and has underscored state government’s failure to stop program fraud in recent years.

The woman said that even months after contacting the DHS Office of Inspector General — which can halt payments and refer cases for prosecution — nobody followed up with her.

Without licensing, DHS can’t track caseload size or staffing ratios. Last year, the Legislature directed DHS to study whether to begin licensing autism centers and better regulate them.

Despite the rapid growth of the state autism program since launching in mid-2015, many children with autism spectrum disorder still aren’t receiving the services they need due to a shortage of providers, which illustrates the problem with widespread fraud in government programs — resources that should be supporting children in need are instead lining the pockets of scammers. Smart Therapy is still an active provider, according to DHS.

A DHS spokesperson said in a statement that all reports of suspected fraud or abuse are reviewed, but “due to the volume of reports received, the department only reaches out to people if more information is needed.” And investigatory data is not public under state law, so the agency isn’t able to share updates about investigations until they’re resolved.

Smart Therapy formed in 2019 and quickly became one of the highest paid providers, reimbursed over a half million dollars by the state in 2020 — the 14 th highest amount out of 85 fee-for-service providers that year. (Some Medicaid recipients get their insurance directly through the Minnesota Medicaid program, with providers billing DHS on a fee-for-service basis. Other people on Medicaid get services from private health insurance companies that the state contracts with — known as managed care organizations — for a fixed price per person.)

Smart Therapy was paid the ninth most out of 142 providers in 2021, when it was reimbursed $2.1 million. It was paid the third most out of 206 providers in 2022, at $2.8 million, and the seventh most out of 280 providers last year, when it was paid $2.6 million.

While Smart Therapy rocketed to the top quickly after opening, the autism center also got money from the federal child nutrition program that federal prosecutors say was rife with fraud during the pandemic.

Smart Therapy claimed it served over 199,400 meals and snacks in 2020 and 2021 under the sponsorship of Feeding Our Future — the nonprofit at the center of the federal fraud.

No one from Smart Therapy has been charged in the Feeding Our Future case.

The child nutrition program — funded by the U.S. Department of Agriculture and administered by the Minnesota Department of Education — was designed to feed hungry children as schools and child care centers shuttered. But prosecutors have said very few meals were actually given away; instead, fraudsters filed phony invoices and fake rosters of children to steal over $250 million. Seventy people have been charged so far, and 23 have been convicted while dozens more await trial.

Smart Therapy was reimbursed over $465,000 for the child nutrition program in 2020-2021, and over $85,000 in 2019, when it was reimbursed for nearly 41,000 meals and snacks under the sponsorship of Partners in Nutrition, the other nonprofit enmeshed in the federal case.

DHS Inspector General Kulani Moti said in a statement that fraud is unacceptable, and DHS set up programs to prevent it as often as possible. She said some of the people with connections to Feeding Our Future have been disqualified from working in a DHS-funded provider organization for 15 years.

“Some of the individuals were controlling individuals in the provider organizations and we revoked the licenses and stopped payments,” she said, without providing specifics.

But to the former Smart Therapy employee, DHS is failing to do even the basics.

“No one has contacted me,” she said about a month after the Reformer forwarded her concerns to the OIG at her request.

‘Some were absolutely horrific’

An early childhood special education public teacher said she and colleagues have been concerned about questionable practices at some Minnesota autism centers. “These are popping up and it’s super shady. … This year they’re coming out of the woodwork.”

The source, who was granted anonymity because she was not authorized to speak by her employer, does initial evaluations of children up to age 5, and talks to parents about any concerns. Some 3- to 5-year-old children attend her school’s half-day program and then get bused to autism centers.

She said some operators of those autism centers are unhappy that the school has children for half of the day, e.g., taking their clients.

“There’s been a lot — particularly this year — of families opting out of early childhood special ed options because they don’t want to lose their programming with this autism center,” said the employee.

Families she worked with said they were told by autism providers to continue with autism center programming rather than starting school, which has specialized programming for ages 3 to 5.

Often immigrant families have little understanding of the autism center’s purpose, she said. Some parents have never heard of autism, even though their kids are in an autism center. Some think their children are going to regular child care, when actually they’re going to an autism center. One father told her the autism center offered “free child care.” His daughter was diagnosed with a speech delay, not autism.

The teacher made it her mission to get inside some of the autism centers to see what they were like, and said she got into five last year. Some of the centers were located in “crazy business parks,” she said.

“It’s like somebody had taken a business office and gotten rid of everything,” she said.

Often she found a lot of young staff members — many glued to their phones — and few children. Not one had a speech clinician on site. There were few toys or core boards, visuals or other learning or therapy materials. Sometimes, she said, the employees seemed to be putting on a show for their visitors.

“Some were absolutely horrific,” she said. Some were using a decades-old, now-controversial intensive, one-on-one treatment called applied behavior analysis, or ABA, but she said it was poorly done: She saw one behavior technician instruct a child to “sit,” “stay,” and “spin.”

“It was terrible,” she said.

Meanwhile, the parents rarely get past the waiting room — if they get there at all, since many children are transported alone in taxi cabs or vans, free of charge — to see what’s happening, she said.

Somali ‘autism moms’ call for more training

A 2009 Minnesota Department of Health study found the proportion of 3- to 4-year-old Somali kids receiving autism services was as much as seven times higher than non-Somali children. More recent data show the disparity has only grown.

The prevalence of autism is significantly higher among Somali 4-year-olds, at 1 in 16, compared to the overall Minnesota rate of 1 in 53, according to Jennifer Hall-Lande, investigator with the Minnesota Autism and Developmental Disabilities Monitoring Network, which is funded by CDC to research the number of children with autism in Hennepin, Anoka and Ramsey counties.

The rate among 8-year-old Somali children is comparable to all Minnesota children — 1 in 34 children — which is slightly higher than the average among 11 states tracked by the Centers for Disease Control and Prevention.

Hall-Lande said the data can’t explain why the prevalence is so high among Somali 4-year-olds. Anecdotally, Hall-Lande said, there could be greater awareness of autism in some communities, resulting in earlier referral and identification. Some children may be served under a different eligibility category at older ages, or some older children may leave the public schools and go to charter schools, she said.

In the wake of news that autism centers are under federal scrutiny, a group of self-described “autism moms” say more training is needed for providers serving the many Somali-descended children on the spectrum.

Idil Abdull is a Somali-American immigrant whose son has autism, which led her to advocacy. She opened an autism therapy agency and co-founded the Somali American Autism Foundation of Minnesota.

She and other Somali parents of children with autism fought for years to get the state Medicaid program to pay for applied behavior analysis for low-income children on managed care plans. ABA focuses on changing behaviors and takes more hours of repetitive therapy, and thus higher reimbursement.

Abdull said before immigrant providers entered the field, white providers bullied and discriminated against parents of children of color. Minority providers saw the need to provide autism services beyond the 9-to-5 workday and stepped in to provide evening and weekend hours, she said.

She said DHS needs to do a better job of educating some communities about autism, and the rules and regulations governing autism centers, to help them succeed.

“When a minority agency sneezes the wrong way, DHS has a meltdown, but when a non-minority agency does something wrong, they don’t even blink,” Abdull said. “We worked too long and too hard since 2007 for our children in Minnesota and nationwide to let anyone, including DHS, dismiss our pain and challenges.”

Fatima Molas, co-founder of the Multicultural Autism Action Network, said Somali parents met a few times with a DHS autism official to give ideas for how to help the community, but there was no follow through.

Molas and other Somali autism moms called on DHS to provide culturally appropriate training to minority providers. Molas said before more immigrant providers entered the market, families were wait-listed and would never get a phone call from autism centers. Newer providers that better represent diverse communities are more flexible, offering services beyond the traditional 9-5 work day, some of them advertising that they’re open seven days a week.

The number of providers who diagnose and treat autism has increased from 41 providers in 2018 to 328 last year. The amount paid to providers during that time climbed from about $6 million to nearly $192 million.

The Autism Treatment Association of Minnesota says the rapid increase in the number of providers and payments correlates with the launching of the state program in 2018. But the group has advocated for stronger licensure and oversight of service providers, supporting a bill — passed last session — requiring people who practice applied behavior analysis and use the title of behavior analyst to be licensed by the Minnesota Board of Psychology.

Abdull opposed licensing behavior analysts but supports licensing autism centers, because, she said, “These are vulnerable kids; they can’t speak for themselves.”

Eric Larsson, executive director of clinical services for Lovaas Institute Midwest, which provides autism services to children in their homes and community, serves on a national certification board that responded to 2018 fraud allegations in Florida by setting up a special unit to process the complaints. That state found therapy providers billing for more than 24 hours in a day, billing for 31 consecutive days, and falsifying qualifications.

Larsson used to think Minnesota had too many bureaucratic hurdles. But he said without the safeguard of licensing, the same type of fraud could happen here.

Employees defend center

Smart Therapy Center is inside a brick building with blue awnings on the front and an outdoor play area, on Hennepin Avenue just south of Franklin Avenue.

On a recent morning, the front door of the building was locked, with a buzzer that nobody answered, although a few minutes later three Smart Therapy employees came out so one could show the other two her new car.

They said there were two children inside the center that day, fewer now that regular school is in session. They said it’s a good place to work.

They declined to give their names.

Another woman showed up — but wouldn’t give her name — and said she’s worked there for three years. She said Smart Therapy gave away food during the pandemic and does an “amazing job.” Parents express gratitude for the therapy, she said. The owner would not be coming, she said, and the center director was out for a medical issue. She declined to allow a reporter inside to see what was behind the locked front door.