To fight fraud, go in with the new, out with the Whac-a-Mole

In 1976, Aaron Fechter invented an aggravatingly simple game that would quickly become strangely addictive and wildly popular. The game, which he dubbed "Whac-A-Mole," would grow to be of the most unanimously recognizable arcade games to date, and a staple in every arcade in America, but its inventor would never see a dime.

According to Fechter, who told his version of the story in the 2010 documentary "Rock-afire Explosion," he actually got the idea from "a bunch of Japanese guys" at a trade conference. Fechter rebuilt the game for a carnival operator, who later sold the prototype to a game manufacturer in Florida who began mass producing the game.

Fechter might have lost the fame and fortune tied to the Whac-A-Mole franchise, but his societal contribution goes beyond an inane game featuring animatronic moles and an oversized mallet. The term "Whac-A-Mole" grew into a popular colloquialism used to describe a desperately futile task. Nowhere is that phrase more universally used and understood than in the healthcare fraud industry.

In fact, the Whac-A-Mole terminology is such a fitting description for healthcare fraud that it's become a crutch catchphrase for prosecutors, most notably Wilfredo A. Ferrer, the U.S. attorney general for the Southern District of Florida. Just last month, Ferrer told Law 360 that South Florida is in a "constant game of Whac-A-Mole" to prevent healthcare fraud.

"We emphasize the eradication of one type of fraudulent scheme, and the fraudsters catch on to that and switch to another," he said.

If this sounds like a familiar slogan, it's because Ferrer, and others, use it as a kind of verbal tic when discussing fraud, waste and abuse.

  • Last May, Ferrer said the same thing in a Reuters article announcing the arrest of 90 people in a $260 million Medicare scheme and again in 2012 in an interview with the South Florida Business Journal.
  • He had the same response in a 2010 Miami Herald article about pervasive mental health and rehab fraud in South Florida.
  • He's used it to describe tax fraud and a $10 million business loan fraud scheme.
  • As far back as 2007, the Centers for Medicare & Medicaid Services, the Office of Inspector General and the Department of Justice even used it in an official capacity, partnering to form Operation Whack-A-Mole, which recovered over $11 million and resulted in 43 indictments of DME suppliers in Florida.

I can understand why Ferrer leans on the phrase. In many ways, it's the perfect way to describe a system constantly struggling to keep pace with fraudsters savvy enough to jump from one industry to the next depending on where the prosecutor's mallet is aimed. The problem is that prosecutors in Florida have been using this snappy colloquialism to describe healthcare fraud for nearly a decade without changing the approach. At what point do you try and change the game altogether?

The healthcare industry has been talking about predictive analytics for some time now. In some states, that transition is taking root, with investigators pulling information from multiple commercial databases to build the foundation of a fraud investigation.

But that's not the case everywhere. In many states, the criminals still outpace the investigators. Recently, the crime du jour has been home health care. Thanks to an 18-month moratorium on new home health provider applications, Ferrer tells Law 360 that prosecutors have been able to snag more of the home health fraudsters who plague South Florida, bringing criminal charges against 220 individuals since 2011. This mimics a similar effect in 2007, when South Florida prosecutors went after durable medical equipment suppliers. The game continues.

It's certainly a serviceable approach: Find a high-risk area, assemble a taskforce and whack away until the criminals scatter. Indictments, arrests and recoveries spike. Prosecutors point to it as a job well done. But it's also one in which prosecutors and investigators constantly play catch-up with the criminals--and perpetuating that approach only widens that gap between them.

Ferrer admits that, in light of the home health crackdown, Medicare Part D fraud, a longstanding concern, is already showing signs of vulnerability. If the aim is to stop fraud before it happens, the Whac-A-Mole approach has been ineffective for some time now, particularly in South Florida, which has earned the dubious honor as the nation's fraud capital. Yet year after year, Ferrer obediently repeats the same three words.  

Compare a hulking Whac-A-Mole machine to the latest video game console and it seems downright archaic. You might stumble upon a Whac-A-Mole game, usually collecting dust in the back corner of an old arcade. It's a relic now, and its antiquity might offer a few moments of entertaining nostalgia--but it's also been surpassed by more technologically advanced video games with HD graphics, cameras, and sensors that can read every move, even as you make it. 

The same can be said for the methodology used to fight fraud across the country. After talking about it for close to a decade, we need to move away from the reactive Whac-A-Mole approach that's no longer viable to curbing fraud, waste and abuse.

There certainly is hope that we are headed in that direction. The Affordable Care Act provides more funding and resources toward fraud detection, including the Healthcare Fraud Prevention Partnership. A startup called TrueClaim is using analytics to identify suspicious claims and double-check them with patients. The biometrics market is poised for a significant growth spurt, which could curb medical identify theft and make it more difficult for physicians to submit false claims.

It's not something that will happen overnight, but it's an optimistic shift from reacting to fraud to preventing it. - Evan (@HealthPayer)

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