by Terence Blackwell Jr on January 27, 2026
In a recent column, 6 Revenue Strategies IDD Providers Should Be Evaluating Now, I outlined several ways intellectual and developmental disabilities (IDD) providers can strengthen their financial sustainability in an environment where Medicaid alone can no longer be assumed to keep pace. One of those strategies consistently generates the most follow-up questions: applied behavior analysis (ABA).
For IDD providers evaluating whether to add ABA services, the question is no longer whether demand exists, but whether their organization is operationally prepared to deliver it at scale.
That interest is understandable. Autism prevalence continues to rise, demand for services far exceeds supply, and ABA is now a fully integrated part of mainstream healthcare with established billing codes and mandated insurance coverage for children ages 0 to 21 in all 50 states. ABA has moved from a niche intervention to a core autism treatment reimbursed by Medicaid and commercial insurance, placing it squarely at the intersection of healthcare, education, and disability services.
But I have also seen applied behavior analysis service lines fail more often than they succeed when organizations underestimate what it takes to do ABA well. The issue is rarely whether ABA is needed; we know it is. The issue is whether a provider is prepared to build it as a true business line rather than attempting to layer it onto existing operations. In practice, successful ABA expansion follows a predictable pattern, regardless of organizational size or geography.
What It Takes to Build an ABA Service Line
Based on years of operating an ABA agency and advising organizations that have tried to launch one, I have identified four key steps that largely determine whether an ABA expansion becomes a sustainable asset or an expensive lesson.
1. Build the Right Team
The first and most critical requirement for launching ABA services is leadership. The most common mistake I see is treating ABA as an add-on responsibility. Assigning oversight to an already stretched executive or clinical leader almost guarantees problems. ABA is a clinical service that requires focused leadership, consistent supervision, and a clear quality culture.
Competency alone is not enough. Someone may be highly qualified and still be unable to carry the additional workload that ABA demands. Successful programs almost always have a dedicated champion, typically a board-certified behavior analyst (BCBA), whose primary responsibility is building and protecting the integrity of the service line. Optimally, organizations will bring in multiple, experienced BCBAs.
But given the shortage of experienced BCBAs, many organizations find success by partnering with universities to support practicum and supervision pathways. These relationships take time to develop, but they create a pipeline of talent and help anchor the program in evidence-based practice from the start.
2. Use a Strong Electronic Records System
Documentation is the primary compliance risk in applied behavior analysis service delivery. ABA is unforgiving when it comes to documentation. Insurers and Medicaid programs expect precise records that demonstrate medical necessity, services delivered, and measurable progress over time. Audits are routine, and sampling and extrapolation methodologies mean that even small documentation gaps can quickly turn into large repayment demands.
This risk is no longer limited to Medicaid. Commercial insurers now use similar audit tools. If even just two to three percent of notes are missing signatures or contain date errors, payers may extrapolate that error rate across a much larger population and demand immediate repayment.
IDD providers should treat strong electronic records and the use of an EHR — particularly one designed for IDD services (e.g., Cx360 Enterprise) — as an essential risk management function. Organizations must be able to produce records on demand, document treatment adjustments when progress stalls, and demonstrate that billing aligns precisely with services rendered. Without that capability, ABA will surface operational weaknesses quickly.
3. Set Up Solid Billing Infrastructure
ABA billing succeeds or fails long before claims are submitted. While ABA billing codes are now largely stable and predictable, that does not make billing simple. Successful programs rely on billing professionals who understand healthcare coding, payer rules, authorization management, and the nuances of ABA-specific claims.
There is real revenue potential in ABA, but capturing it depends on execution. Insurers may authorize high rates for BCBA time while reimbursing only a portion of that amount. Much of the financial sustainability comes from the appropriate use and supervision of registered behavior technicians (RBTs). If billing is inaccurate or supervision ratios are off, margins disappear fast.
Organizations that underestimate billing complexity often discover too late that clinical excellence alone does not protect them from financial or regulatory trouble.
4. Diversify Revenue Sources Thoughtfully
Payer concentration is one of the most overlooked risks in ABA program design. Programs are strongest when they are not dependent on a single payer. While insurance reimbursement is central, many organizations also incorporate private pay options, school district partnerships, or a mix of funding sources. Diversification helps stabilize the ABA service line itself and reduces vulnerability to payer-specific policy changes.
These decisions should be made early. How an organization positions its ABA services in the first year often determines whether it can adapt as demand grows and payer expectations evolve.
For organizations asking how long it takes to build a sustainable ABA program, the honest answer is that it depends on preparation. Those with experienced leadership, audit-ready systems and other supporting technology, and billing expertise can often establish stability within the first year. Those without will usually spend that same time correcting avoidable mistakes.
The Difference Between Adding ABA and Building It Well
Applied behavior analysis is one of the most mission-aligned opportunities available to IDD providers today. ABA addresses a real and growing need, and when designed correctly, it can support both quality outcomes and organizational stability. But it is not a shortcut, and it is not forgiving of casual implementation.
The organizations that I have seen succeed treat ABA as a disciplined clinical and operational endeavor. They invest in leadership, infrastructure, documentation, and billing before scaling. Those that do not often find themselves managing audits, turnover, and financial exposure instead of expanding access to care.
Diversification is not about chasing ideas. ABA makes that point very clearly. When approached with seriousness and structure, ABA can become a sustainable service line that strengthens both financial stability and clinical impact for IDD providers.
