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Indiana · IHCP · Applied behavior analysis

$56 million improper, and 97155 failed in 81 of 100 months

In December 2024 the HHS Office of Inspector General finished auditing Indiana's fee-for-service Medicaid payments for ABA in 2019 and 2020. It found improper payments in 97 of the 100 enrollee-months it sampled, at least $56 million across the period, and a further $76.7 million it could not verify from the notes. IHCP has since said in bulletins what a session note must show, that nap time is not billable, and when 97155 counts. This page turns the audit and those bulletins into a checklist for what goes in the note. The matching rule set lives in the rules library in the Penguin Health app, and we update it when IHCP issues the next bulletin.

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In the rules libraryIndiana Medicaid ABA · eight rules · maintained by Penguin · reviewed Oct 12, 2026

Improper payments, 2019 to 2020$56M

OIG's low estimate. The recommended refund is $39,432,556, the federal share.

Potentially improper payments$76.7M

Set aside for the state to review claim by claim.

Sampled enrollee-months with an improper payment97 of 100

958 claims and 2,341 claim lines from 41 facilities.

Months where the note did not support the CPT code81 of 100

Mostly 97155 notes reading "no changes warranted."

OIG audit A-09-22-02002

Where the 100 sampled months failed

OIG sampled 100 enrollee-months of fee-for-service ABA from calendar years 2019 and 2020: 958 claims and 2,341 claim lines from 41 facilities. Then it read the notes. Indiana improperly paid at least $56 million across the period, with a further $76.7 million potentially improper, and OIG recommended a refund of $39,432,556, the federal share.

Counts are enrollee-months out of 100. Most months failed more than one way. Hover or tab to a bar for what OIG saw.

Improper97 of 100Payments OIG says did not meet federal or Indiana requirements. These drive the refund.

Note did not support the CPT code billed81
81 months97155 notes reading "no changes warranted." 97156 notes recording a general discussion with parents rather than guidance to implement protocols.
Note did not support the units billed52
52 monthsUnits above the documented time. Nap time billed. ABA billed during speech therapy. Two RBTs billed at once. Notes signed before the session ended, or before it started.
No valid signature39
39 monthsUnsigned notes, notes signed by someone other than the provider, and BCBAs signing months after the date of service.
Staff lacked the required credential26
26 monthsServices rendered by uncredentialed staff.
No valid diagnostic evaluation or referral22
22 monthsNo valid diagnostic evaluation or referral for ABA on file.
Session notes missing17
17 monthsNotes could not be produced for one or more paid dates.

050100

Potentially improper100 of 100Payments OIG could not verify from the note. Set aside for Indiana to review.

No detailed statement of the service98
98 monthsAs few as three or four sentences for eight hours of ABA.
Potential non-therapy time97
97 monthsBilled continuously for up to eight hours with no deduction for meals, breaks, or naps.
Recreational or academic activities61
61 monthsA tablet and the movie Smurfs 2. "Functional academics." Spelling tests.
Group activities billed as individual37
37 monthsGroup work billed under the one-to-one code.

050100

Source: OIG A-09-22-02002, Findings. "Improper" and "potentially improper" are OIG's categories. Session notes did not meet requirements in 95 of the 100 months. OIG also found cloned notes and notes carrying the wrong child's name.

View as a table

OIG category	Finding	Enrollee-months
Improper	Session notes did not meet requirements (any of the four rows below)	95
Improper	Note did not support the CPT code billed	81
Improper	Note did not support the units billed	52
Improper	No valid signature	39
Improper	Session notes missing	17
Improper	Staff lacked the required credential	26
Improper	No valid diagnostic evaluation or referral	22
Potentially improper	No detailed statement of the service	98
Potentially improper	Potential non-therapy time	97
Potentially improper	Recreational or academic activities	61
Potentially improper	Group activities billed as individual	37

The checklist

Ten things an Indiana note has to show

The IHCP Behavioral Health Services module and BT2024194 set the note: signed by the practitioner who rendered the service; the date, time, location, and duration; the skills targeted in that session; and the member's response tied to treatment-plan goals. BT202519 adds the participants, or an explanation when the parent or guardian was absent. BT2026159 says nap time is not billable and children may not be kept awake to continue a session. The OIG report supplies the rest: who signs, when, and what is not ABA.

Here is that requirement as a technician's note for a home session with a recorded and deducted nap, each element tied to the document that requires it and the OIG finding behind it. The member, staff, and data are fictional.

Session note97153 · Adaptive behavior treatment by protocol

Member: L. S. (full name on file) · IHCP member ID TEST-00351 · DOB 02/18/2021
Date and location: 10/07/2026 · Home, Fort Wayne, IN 2
Time and duration: 9:00 am to 2:00 pm. Nap 11:30 to 12:15 recorded and deducted. 4 hours 15 minutes billed, 17 units. 26
Participants: Member and RBT. Mother present from 1:30. Father not present (at work). 5
Rendering: Marisol Vega, RBT 1

Skills targeted in this session 3

Requesting a break (plan goal 1). Functional communication training, 4 blocks. 16 of 20 independent (80%); 65% on 10/05.
Imitating gross-motor actions (plan goal 4). Discrete trial training. 11 of 15 correct with a model.
Tolerating transitions (behavior plan). Timer plus first-then board. 1 instance of flopping, 50 seconds, recovered.

Response, tied to the treatment plan 4

L. used the break card independently in 16 of 20 opportunities, up from 13 of 20 on 10/05, which meets the plan's 80% criterion for the first time; the RBT will run two more sessions at criterion before the BCBA reviews the goal. Imitation held at 11 of 15 with a model. One flop at the transition from the table to the floor mat, 50 seconds; the timer and first-then board ended it. L. fell asleep at 11:30 and the RBT did not wake him; he woke on his own at 12:15 and the session resumed. The nap is not billed. No protocol changes. 8

Signed electronically: Marisol Vega, RBT · 10/07/2026 2:09 pm 17

1
Signed by the practitioner who rendered it
The RBT who delivered the session signs the note. The state told OIG that an RBT's note must be signed by the RBT, not by a supervisor on their behalf.
Indiana IHCP Behavioral Health Services module · BT2024194 · OIG A-09-22-02002, footnote 33
39 monthsUnsigned notes, notes signed by someone other than the provider, and BCBAs signing months after the date of service.
2
Date, time, location, and duration
When and where, and how long, as a start, an end, and the minutes billed.
Indiana IHCP Behavioral Health Services module · BT2024194
52 monthsUnits above the documented time, and notes signed before the session ended or before it started.
3
The skills targeted in this session
Which skills were worked on today, named against the treatment plan, with the technique used.
Indiana IHCP Behavioral Health Services module · BT2024194
98 monthsAs few as three or four sentences for eight hours of ABA.
4
The member's response, tied to treatment-plan goals
How the member responded, with data, and what it means against the plan's goals.
Indiana IHCP Behavioral Health Services module · BT2024194
IN-1The elements in items 1 to 4, each with real content.
5
Participants listed, or the parent's absence explained
Who took part. When the parent or guardian was not there, the note says why.
Indiana BT202519
IN-2Participants, or the explanation.
6
A nap recorded and deducted, and the child not kept awake
Nap time is not billable, and children may not be kept awake to continue a session. A nap that is recorded and deducted is correct; a nap inside billed time without deduction is not.
Indiana BT2026159, September 29, 2026
97 monthsBilled continuously for up to eight hours with no deduction for meals, breaks, or naps.
IN-5From September 29, 2026. A recorded, deducted nap passes.
7
Signed at or after the billed end time
Time billed after the note was signed is not documented at the time of service. The signature time is at or after the billed end time, with no grace period.
Indiana OIG A-09-22-02002, footnote 33
IN-7Any signature before the billed end time fails.
8
Only ABA
No recreation without a technique, no academics, and no group activity billed as 97153.
Indiana OIG A-09-22-02002
61 monthsA tablet and the movie Smurfs 2. "Functional academics." Spelling tests.
37 monthsGroup activities billed as individual.
IN-6Recreation with no technique, academics, or group activity billed as 97153.
9
97155: a protocol change, with the technician directed
97155 counts only when the note shows a protocol modification and the analyst directing the technician with the member present. Not shown in this 97153 example.
Indiana BT202662 · OIG A-09-22-02002
81 monthsMostly 97155 notes reading "no changes warranted."
IN-3"No changes warranted" fails.
10
Telehealth only on 97155 and 97156
From April 1, 2026, telehealth (modifier 95) is allowed only on 97155 and 97156. Not shown in this in-person example.
Indiana BT202627
IN-8From April 1, 2026. Fails 97151 to 97154 or 0373T billed with place of service 02 or 10.

Supervision, one hour per eight

One hour of supervision per eight hours of technician time (1:8), per member, per calendar month.

Requirement onlyBT202662. A requirement on the practice. Penguin does not track supervision for Indiana.

The April 1, 2026 claim changes

Credential modifiers U1 RBT, U2 BCaBA, U3 BCBA, BCBA-D, or psychologist; group-size modifiers U4, U6, U8; comprehensive ABA carries UA and counts toward a 4,000-hour lifetime cap; no payment for members 21 and older for dates of service from October 1, 2026; rates cut 6% with another 4% on April 1, 2027.

Requirement onlyBT202627. Of these, only the telehealth rule is something Penguin checks (IN-8). IHCP says its documentation rules apply to managed care entities; Penguin does not know whether a given MCO enforces the modifiers.

Coming due

A functional behavior assessment for each behavior targeted by a behavior plan from October 29, 2026, and agency accreditation by October 1, 2027.

Requirement onlyRequirements on the practice. Penguin does not check either.

The 97155 problem

The code that failed in 81 of 100 months

97155 is adaptive behavior treatment with protocol modification. In 81 of the 100 sampled months the note did not support the code billed, and most of those were 97155 notes reading "no changes warranted," with 97156 notes recording a general discussion with parents close behind. BT202662 now says it plainly: 97155 counts only when the note shows a protocol modification and the analyst directing the technician with the member present.

Supports 97155

A protocol change named, with what changed and how the member responded.
The analyst directing the technician, during the member's session.
The member present, and the note says so.

Does not support 97155

"No changes warranted." The phrase OIG quoted from month after month of 97155 notes.
A general discussion with parents. Not 97155, and not 97156 either: 97156 is guidance to carry out protocols.
A copy of an earlier note, or a note with another child's name on it.

IN-3 · 97155 documents a protocol change with the technician directedFAIL

applies_when: procedure code contains 97155
rule_text: Pass when the note names the protocol change, shows the analyst directing the technician, and places the member in the session. "No changes warranted" fails.
protocol_change_named: false
rationale: Narrative states "Observed session; no changes warranted at this time." No change, no direction.

What the reviewer gets: the finding, the analyst's educational email, and the action steps to amend or rebill, pre-filled with the date of service and a link to the note.

IN-4 · 97156 gives caregivers guidance to implement protocolsFAIL

applies_when: procedure code contains 97156
rule_text: Pass when the note shows caregivers being taught to carry out protocols. Fail for general discussion.
guidance_to_implement: false
rationale: Narrative states "Discussed progress and upcoming schedule with mother." No protocol taught.

What the reviewer gets: the finding, the analyst's educational email, and the action steps to amend or rebill, pre-filled with the date of service and a link to the note.

Billable time

A day is not a session

One case from the OIG report says it all. A child received ABA from 10:00 a.m. to 4:20 p.m., which is 25 units. The facility billed 29. A 45-minute nap inside that window, 3 units, was not deducted. The facility was overpaid by 7 units for the day. In 97 of the 100 sampled months, ABA was billed continuously for up to eight hours with no deduction for meals, breaks, or naps (OIG A-09-22-02002).

Since September 29, 2026, BT2026159 says nap time is not billable and children may not be kept awake to continue a session. The note that gets this right records the nap, deducts it, and bills the minutes that were treatment.

The OIG worked example, drawn to scale. The nap's placement is illustrative; the report gives the session times, the units billed, and the nap's length. Where the nap fell, 22 units were supportable: 25 for the session, less 3 for the nap. 29 were billed.

In the rules library

Eight Indiana rules, ready to turn on

Open the rules library in the Penguin Health app, choose Indiana Medicaid ABA, 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 Indiana Medicaid managed care plans. Penguin checks the CentralReach payer name, so a Indiana rule never fires on an Anthem commercial note in the same organization. The match is on payer names that contain the state's Medicaid label (for example "IN Medicaid MCE"), and an organization whose payer names differ edits that match 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. Both means the AI reads a value off the note and a deterministic check makes the decision.

IN-5 applies to sessions on or after September 29, 2026, the date of the nap bulletin, and IN-8 to sessions on or after April 1, 2026, when the telehealth rule took effect. Older sessions are skipped, not failed. The other six rules apply to all dates.

Rules libraryPenguin Health app

Indiana Medicaid ABAMaintained by Penguin

Eight rules for IHCP applied behavior analysis, each with QA guidance by program code.

reviewed: Oct 12, 2026
runs on: Notes billed to Indiana Medicaid managed care payers · IN-5 from Sep 29, 2026 · IN-8 from Apr 1, 2026 · the rest all dates
sources: OIG A-09-22-02002 · IHCP Behavioral Health Services module · BT2024194 · BT202519 · BT202627 · BT202662 · BT2026159 · BT2026162
watching: FBA requirement, Oct 29, 2026 · Agency accreditation, Oct 1, 2027 · Second rate cut, Apr 1, 2027

Add to organizationAdds all eight rules and their QA guidance. Edit any rule afterward, or add your own alongside them.

Indiana requirement	What Penguin checks on every note	Indiana source	How
Required session-note elements are presentIN-1 · items 1 to 4	Signed by the practitioner who rendered it; date, time, location, duration, skills targeted, response tied to plan goals.	IHCP module; BT2024194	AI
Participants listed, or the parent's absence explainedIN-2 · item 5	Who took part, or why the parent or guardian was not there.	BT202519	AI
97155 documents a protocol change with the technician directedIN-3 · item 9	A named protocol change, the technician directed, the member present. "No changes warranted" fails.	BT202662; OIG A-09-22-02002	AI
97156 gives caregivers guidance to implement protocolsIN-4 · The 97155 problem	Teaching caregivers to carry out protocols; general discussion fails.	OIG A-09-22-02002	AI
Nap time is documented and deducted, and the child is not kept awakeIN-5 · item 6 · from Sep 29, 2026	A nap inside billed time without deduction fails, as does keeping a child awake. A recorded, deducted nap passes.	BT2026159	AI
No recreational, academic, or group content billed as ABAIN-6 · item 8	Recreation with no technique, academics, or group activity billed as 97153.	OIG A-09-22-02002	AI
Signed at or after the billed end timeIN-7 · item 7	Any signature before the billed end time fails. No grace period.	OIG A-09-22-02002, footnote 33	Deterministic
Telehealth only on 97155 and 97156IN-8 · item 10 · from Apr 1, 2026	Fails 97151 to 97154 or 0373T billed with place of service 02 or 10.	BT202627	Deterministic

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. And because the rules live in the library rather than in a template, an update from Penguin reaches every organization using the set. Billing Medicaid in more than one state? The rules library covers sixteen, including Wisconsin and Missouri.

Maintained by Penguin

We watch IHCP so the rules never go stale

IHCP has issued a run of bulletins since the audit, two of them in 2026 with their own effective dates. The Indiana set is tied to those documents, not to a template written once. Here is how it stays current, and what each change so far did to the set.

Watch

The IHCP Behavioral Health Services provider reference module, the IHCP bulletin series, the behavioral health code table, and OIG and state program-integrity reports.

Update

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, so you can see it is current without asking us.

Re-run

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.

Dec 16, 2024
OIG publishes the audit
Improper payments in 97 of 100 sampled months and at least $56 million improper across 2019 and 2020. The state tells OIG that an RBT's note must be signed by the RBT, and that time billed after the note was signed is not documented at the time of service.
LibraryIN-3, IN-4, IN-6, and IN-7 cite the report's findings and footnote 33.
2024
BT2024194, session-note requirements
The note is signed by the practitioner who rendered the service and carries the date, time, location, duration, the skills targeted, and the member's response tied to treatment-plan goals.
LibraryIN-1 cites this bulletin alongside the provider module.
2025
BT202519, participants
Participants are listed, with an explanation when the parent or guardian was absent.
LibraryIN-2 cites this bulletin.
2026
BT202662, 97155 and supervision
97155 counts only when the note shows a protocol modification and the analyst directing the technician with the member present. Supervision is one hour per eight hours of technician time, per member, per calendar month.
LibraryIN-3 cites this bulletin. The 1:8 ratio is a requirement on the practice; Penguin does not track it.
Apr 1, 2026
BT202627, claim changes
Telehealth (modifier 95) only on 97155 and 97156; credential, group-size, and UA modifiers; a 4,000-hour lifetime cap on comprehensive ABA; no payment for members 21 and older from October 1, 2026; a 6% rate cut with another 4% on April 1, 2027.
LibraryIN-8 applies to dates of service on or after this day. The modifiers and caps are requirements only.
Sep 29, 2026
BT2026159, naps
Nap time is not billable, and children may not be kept awake to continue a session.
LibraryIN-5 applies to dates of service on or after this day. Older sessions are skipped, not failed.
Oct 12, 2026
Indiana set reviewed
Checked against the OIG report, the IHCP Behavioral Health Services module, and bulletins BT2024194, BT202519, BT202627, BT202662, BT2026159, and BT2026162. Current.
Watching
The FBA requirement, accreditation, and the second rate cut
A functional behavior assessment for each behavior targeted by a behavior plan from October 29, 2026; agency accreditation by October 1, 2027; the second rate cut on April 1, 2027. When IHCP publishes the next bulletin, the set is updated and every organization using it gets the change.

Next step

Run a month of Indiana notes through Penguin

Bring one month of 97153 and 97155 notes. We add the Indiana set from the rules library, run it, show every finding beside the OIG category or bulletin 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.

Book a demo Get a demo account

This page summarizes public documents for ABA providers in Indiana and is not legal or billing advice. Requirements change; everything here, and the Indiana Medicaid ABA set in the Penguin Health rules library, was reviewed against the sources below on October 12, 2026. When a source changes, the set is updated and the review date moves with it. The example note, its client, staff, and data are fictional. CPT is a registered trademark of the American Medical Association.

HHS OIG, Indiana Made at Least $56 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children Diagnosed With Autism, A-09-22-02002, December 16, 2024 (findings, counts, examples, the worked nap example, and footnote 33); summary page
IHCP Behavioral Health Services provider reference module (session-note elements)
IHCP bulletin BT2024194 (session-note elements)
IHCP bulletin BT202519 (participants listed, parent absence explained)
IHCP bulletin BT202627 (April 1, 2026 changes: telehealth on 97155 and 97156 only, modifiers, the 4,000-hour cap, age limit, rates)
IHCP bulletin BT202662 (97155 as protocol modification with direction; 1:8 supervision)
IHCP bulletin BT2026159, September 29, 2026 (nap time not billable; children not kept awake)
IHCP bulletin BT2026162
IHCP behavioral health services code table