When it comes to
health care fraud, sometimes the numbers alone reveal the crime. We know that one person cannot work more than 23.99 hours per day, since there are only 24 hours in a day. But for some fraudsters, this concept has not clicked — and their billing records reveal just how far they have pushed the limits. Experts call it the “Impossible Day” or “High-Day Billing.”
Impossible Day Fraud Schemes
Impossible day fraud schemes are defined as occurring when a health care provider purports to provide such a high volume of patient services or procedures in single day (24-hour period) that there is no way the provider could have reasonably performed them.
Current Procedural Terminology (CPT) Codes — established by the American Medical Association to ensure consistent billing and data collection — are particularly vulnerable when time is a critical part of the services provided.
Behavioral health CPT codes are especially susceptible to this type of manipulation. David Judd, a Nurse Practitioner (NP) in Clinton Township, Michigan, who practiced mental health treatment was convicted of operating such a scheme. As an NP, Judd had the authority to prescribe medication.
The Background
In September 2012, Judd formed Life Transition Services, Inc. as a “staffing services” company, eventually establishing an office in Clinton Township. Judd’s journey to becoming a Nurse Practitioner was a unique one, according to his attorneys. In their Sentencing Memorandum, they detailed his life:
He grew up in a poor neighborhood in humble circumstances where he did have difficulties at home. As a young man, he found himself cutting meat as a profession. Sensing that this was not the career path he ultimately wanted to walk, Mr. Judd used the money he earned in the decade he worked at the meat cutting facility to put himself through community college and eventually graduated with a psychology degree from Oakland University.
From there, he began a career in health care, first as a mental health technician at a hospital, and later working with elderly patients at a second hospital. In 1994, he obtained a degree in nursing and, in 2011, became an NP after completing the NP master’s program at Wayne State University.
Judd’s Fraud Scheme
Prosecutors, in their overview of the case presented during sentencing, described a different side of Judd, stating that Judd’s scheme (which ran from 2015 to 2021) was brazen: “Judd caused the submission of false and fraudulent claims to Medicare for psychotherapy services that were not medically necessary, not rendered and/or not eligible for Medicare reimbursement.”
According to a federal search warrant obtained in September 2021, Medicare data showed that Judd — and unlicensed social workers who worked for him — submitted numerous claims that exceeded the 24-hour clock. The analysis revealed that Judd submitted claims for 164 days between 2015 and November 2020, which were determined to be implausible. Medicare paid more than $525,000 for these submissions.
For example, on May 12, 2018, Judd claimed to have seen 58 patients during that day and billed more than 45 hours in face-time with these patients. Similarly, on November 10, 2018, he saw 52 patients and billed for nearly 40 hours for that day. Judd also submitted claims for patients he allegedly saw when he was actually traveling out of state.
One indicator, aside from the sheer incredibleness of the volume of hours and patients seen on a single day, were the notes in the electronic health records. These proved to be invaluable to the investigators, as they began compiling a pattern of impossible day billing. These reviews found that progress notes for claimed dates of service either did not exist or had been provided by ineligible providers, such as the social workers.
Health record progress notes showed that he had been claiming to see multiple patients during the same blocks of time, another impossibility. Finally, these progress notes also indicated that Judd had only conducted a routine 20-minute medication review and used the CPT 99213 but billed Medicare for an additional 30-minute psychotherapy session using CPT code 90833.
The Outcome
Two days after the raid on his office,
Judd was indicted on four counts of health care fraud. Following some procedural motions, Judd ultimately pleaded guilty. In total, Judd submitted or caused to be submitted $1,248,519.94 in false and fraudulent claims to Medicare, resulting in payments of $605,701.30 because of Judd’s fraudulent acts.
Other Examples of Impossible Day Schemes
Judd is not the only example of impossible day fraud schemes. Insurance companies and government investigators have been very active in this space:
Health care investigators, auditors and leaders need to be attuned to this issue, setting controls to ensure that it cannot happen, or if someone does bill for an unreasonable daily amount, they are identified quickly. The Judd case is just one example of the work needed to detect and hold a provider accountable for the impossible day billing scheme.
