Penguin Health
Florida · SMMC · Behavior analysis services
Florida is auditing behavior analysis harder than any state
Florida calls the benefit behavior analysis, and it pays more for it than any other state: $6.57 billion from 2023 through 2025, about four times the next state. In October 2026 the governor's office announced 220+ Medicaid provider terminations and $230 million in suspicious BA billing, and a statutory task force reports recommendations by December 31. The defense is the session note, and the December 2024 coverage policy says exactly what it has to show. The matching rule set lives in the rules library in the Penguin Health app.
About four times any other state, per AHCA data reported by the Florida Phoenix.
With $230M in suspicious BA billing flagged, per the governor's office.
Coverage policy §6.2.4, signed and dated by the rendering practitioner.
Statutory recommendations to the governor and Legislature, possibly including service caps.
2026
The crackdown, and what it means for a clean practice
Since January 2026 AHCA has run hundreds of site visits, put 250+ providers on payment restriction or suspension, and referred 150+ cases to the Attorney General, per the October 6 announcement. The billing patterns named were the crude ones: more than 24 hours billed in a day, services with no qualifying diagnosis. But the mechanism that decides whether an honest practice keeps its money is retrospective review, and retrospective review reads session notes against the Behavior Analysis Services Coverage Policy (December 2024, adopted by Rule 59G-4.125 effective February 10, 2025). Since February 1, 2025 claims run through the recipient's SMMC plan, so plan reviewers apply the same policy.
- Date, time, location, and duration; maladaptive behaviors observed; replacement or compensatory skills targeted; the recipient's response; protocol modifications if any; an explanation if the parent or guardian is absent; and the participants present.
- Signed and dated by the rendering practitioner.
- When the parent or guardian is not participating, the treatment plan and the session notes document the reasons, the potential impacts, and the mitigation.
- Units are 15 minutes. A final partial unit counts only when at least 8 minutes were delivered, so the billed units have to be supported by the documented duration.
- The lead analyst may deliver up to two hours per week of parent or guardian training by telemedicine. Direct treatment is in person.
- Group treatment is limited to six recipients, and intervention is limited to 40 hours per week.
- The behavior plan is signed by the lead analyst and the parent or guardian, and reauthorization carries a data table and graph for every treated behavior.
The checklist
What a Florida BA session note has to show
Section 6.2.4 is the most behavioral note standard of any state: not just who and when, but what behaviors were observed, what skills were targeted in their place, and how the recipient responded. Each item below names its policy section and the Penguin rule that checks it.
| The note shows | What that means in practice | Source | Rule |
|---|---|---|---|
| A signature and date by the rendering practitioner | The person who delivered the service signs and dates the note. A signature by someone else, or an undated one, does not satisfy it. | §6.2.4 | FL-1 |
| Date, time, location, and duration | When and where the session happened and for how long, matching the billed times and place of service. | §6.2.4 | FL-2 |
| Maladaptive behaviors observed | The behaviors seen during the session, or a statement that none occurred. Silence on behaviors is a gap. | §6.2.4 | FL-3 |
| Replacement or compensatory skills targeted | What was taught in place of the behavior, named, not implied. | §6.2.4 | FL-4 |
| The recipient's response to the interventions | How the recipient responded, with data or specific observations, not a list of interventions alone. | §6.2.4 | FL-5 |
| Protocol modifications on the protocol codes | For 97155 and 97158, the modification, goal change, or therapist direction that the code pays for. | §6.2.4 | FL-6 |
| The participants present | Observers, teachers, parents, caregivers, or other providers in the session, listed. | §6.2.4 | FL-7 |
| An explanation when the parent or guardian is absent | Either the parent or guardian was present, or the note says why not. | §6.2.4 · §4.2.2 | FL-8 |
| A duration that supports the billed units | 15-minute units with the 8-minute rounding rule. Units past what the documented duration supports are exposure. | §8.2 | FL-9 |
| A group of six or fewer | Group notes state the participant count, and the cap is six. | Coverage limits | FL-10 |
| In-person delivery for direct treatment | Telemedicine is caregiver training only, up to two hours a week by the lead analyst. Direct treatment billed with a telehealth place of service is not covered. | Rule 59G-1.057 | FL-11 |
The Vineland-3 parent interview form and the BASC-3 PRQ are mandated, repeated on the policy's cadence, and submitted with authorization requests.
Authorization before services begin and at least every 180 days, through the SMMC plan for enrolled recipients.
Requests for school-based BA carry the IEP, a 504 plan, or a documented explanation.
In the rules library
Eleven Florida rules, ready to turn on
Open the rules library in the Penguin Health app, choose Florida Medicaid Behavior Analysis, and click Add to organization. Rules your organization already has are left alone, so adding the set twice only fills gaps. After adding, edit any rule or add your own alongside them.
Each rule runs only on notes billed to Florida Medicaid payers. Penguin checks the CentralReach payer name, so a Florida rule never fires on a commercial note in the same organization. Since the February 2025 SMMC carve-in the payer is usually a plan name, and an organization edits the payer match to its own plans after adding the set.
Penguin reads signed session notes from CentralReach, read-only, after signature and before the claim, and runs the set on every note. Deterministic rules compare record fields. AI rules are read by the AI, which returns a pass or fail with a one-sentence reason.
Eleven rules for AHCA behavior analysis services: the §6.2.4 note elements, parent participation, unit rounding, group size, and the telehealth limit.
- reviewed
- Oct 19, 2026
- runs on
- Notes billed to Florida Medicaid and SMMC plan payers
- sources
- BA Services Coverage Policy, Dec 2024 (Rule 59G-4.125) · Rule 59G-1.057
- watching
- The AHCA BA information page and the task force report due Dec 31, 2026
Every failure ships with QA guidance for that program code: an educational email, numbered action steps, and a QA email pre-filled with the date of service and a link to the note. Each reviewer action is written to a write-once audit log with seven-year retention, which is the record you hand a reviewer next time. Billing Medicaid in more than one state? The rules library covers sixteen, including Georgia and South Carolina.
Maintained by Penguin
We watch AHCA so the rules never go stale
Florida rewrote its coverage policy in December 2024, moved BA claims into managed care eight weeks later, and has a task force drafting changes now. The Florida set is tied to those documents, not to a template written once.
The Behavior Analysis Services Coverage Policy and the AHCA BA information page, where new revisions and task force output land. Penguin fetches the sources on a schedule and archives every revision.
We rewrite the affected rule, cite the document that changed it, and date the review. The set shows its sources and review date in the library.
An updated rule runs in the next scheduled validation and on demand against notes you have already reviewed, so a changed requirement shows you exactly which past notes it touches.
- AHCA issues the current coverage policy
The seven-element session-note standard in §6.2.4, adopted by Rule 59G-4.125 effective February 10, 2025.
- BA claims move into SMMC managed care
Claims for enrolled recipients go to the recipient's plan; fee-for-service remains only for the unenrolled.
- The state announces its crackdown results
220+ terminations, $230M in suspicious billing flagged, 250+ providers on payment restriction, per the governor's office.
- Florida set reviewed
Checked against the December 2024 coverage policy and Rule 59G-1.057. Current.
LibraryFL-1 through FL-11 live in the rules library.
- WatchingThe task force report
Due to the governor and Legislature by December 31, 2026, possibly including service caps. When AHCA revises the policy, the set is updated and every organization using it gets the change.
Next step
Run a month of Florida notes through Penguin
Bring one month of 97153 and 97155 notes. We add the Florida set from the rules library, run it, show every finding beside the policy section it maps to, and hand your QA lead the fix for each one. Or get a demo account and click through Penguin on your own time first.