The autism therapy sector remains one of the fastest-growing areas in healthcare, but operators are having to face new challenges as scrutiny around cost, utilization, and billing practices continues to intensify. Medicaid has become a major growth engine for Applied Behavior Analysis (ABA), supported by federal and state coverage mandates. As spending rises, regulators and payors are escalating their response through audits and tighter utilization management, while several states are cracking down on reimbursement levels, eligibility criteria, and benefit administration to better control growth. This scrutiny has increasingly centered on large, private equity-backed platforms, where rapid expansion and scale have increased utilization but also exposure to compliance risk. This whitepaper updates our prior analysis by summarizing these shifting dynamics, and concludes with best practices for providers navigating heightened scrutiny and evolving reimbursement dynamics.