Jayne O'Donnell and Meghan Hoyer

USA TODAY

Exactly how much pain can there be in Brooklyn?

A USA TODAY analysis reveals that some of Medicare's top-earning specialists are in the New York City borough and sharing thousands of Medicare patients in volumes much higher than the norm. In hundreds of cases, patients have seen several pain specialists on the same day, shuffling between therapists who have billed Medicare for tens of thousands of procedures. In one case, a chiropractor and an occupational therapist saw the same patients on the same day more than 11,000 times in 18 months.

These high-earning occupational therapists, chiropractors and physical therapists have given Brooklyn an unusual distinction. It either has the most broken-down group of elderly and disabled patients in the country — or perhaps a big problem with fraud, legal experts say.

This level of sharing is "staggering," says Dan Bowerman, a Philadelphia chiropractor and former insurance company medical director who has assisted in several federal investigations.

Cross-referring patients for financial gain rather than medical necessity — known as churning — would violate the federal anti-kickback statute, says Joseph Mack, deputy chief of the health care and government fraud unit for the New Jersey U.S. Attorney's Office.

USA TODAY analyzed Medicare's referral data, which Mack says is "one of the basic investigative steps" his office takes in fraud probes. Mack's office works closely on cases with the U.S. Attorney for the Eastern District of New York, which includes Brooklyn.

Nationally, the Medicare Fraud Strike Force has charged nearly 1,900 people for their alleged roles in Medicare schemes that have defrauded the program of billions of dollars. The "vast majority" of fraud cases have involved kickbacks, Justice Department officials say.

Leslie Caldwell, the assistant attorney general for the Justice Department's Criminal Division, says kickback payments and beneficiary recruiters often provide practitioners "a steady stream of patients to bill for — often for services never performed — as long as the doctors and other professionals are willing to certify falsely that other services billed to Medicare were medically necessary."

"A pattern of patients getting referred in a tight network is one of the things we would look at," says Mack, whose office has prosecuted dozens of physicians in the last two years in referral kickback cases. "Churning of patients is definitely something we've picked up on based on the data."

And as Manhattan-based FBI supervisory special agent John Casale says, "History has shown there is usually a remuneration for the referral."

Half of the 30 Medicare fraud cases the Department of Health and Human Services and Justice Department highlighted in their 2013 annual report involved kickbacks. About 90% of Medicare fraud cases against physicians involve referral kickbacks, the Justice Department estimates.

Bowerman said those in his field often compete with physical and occupational therapists, who also compete with each other — meaning they'd normally be less likely to refer patients to the other.

Medicare doesn't get notified when one practitioner refers a patient to another. Instead, agency data released this spring, which covers the 18 months from January 2012 to June 2013, includes all instances where at least 11 patients saw one provider and then within 30 days were seen by a second practitioner. Regulators assume a provider sent a patient to another when patients are seen by both in such a short time span.

The USA TODAY analysis found that six practitioners in Brooklyn all regularly saw the same patients, often treating each person dozens of times. Medicare paid the six a total of nearly $15 million in 2012, the only calendar year that payment data is publicly available. Additional practitioners also fed into and benefited from the referral network, but at smaller rates than the top half-dozen.

For example, physical therapist Wael Bakry and occupational therapist Victor Genkin, both part of the network, are the first and second biggest recipients of Medicare money in 2012 in their respective fields.

Medicare paid Bakry about $4.1 million for performing more than 184,000 procedures on 1,959 patients. Genkin brought in more than $2.3 million from seeing fewer than 1,200 patients.

According to Medicare's data, over 18 months the two shared more than 700 clients, who saw both regularly — as many as 25 times each.

The top earning chiropractor in the nation, Brooklyn's Alexander Khavash, was also a top referrer to Bakry and Genkin. According to the Medicare data, Bakry and Khavash shared more than 1,200 patients between them.

Often, but not always, the physical therapist and chiropractor saw patients back-to-back. One group of patients made a total of more than 17,000 visits to both doctors on the same day — an average of 13 times per patient — over an 18 month span.

The patients also regularly cycled through internist Abraham Demoz, who has used the same address as Genkin and Bakry. For example, Khavash saw 2,060 patients in 2012, according to the Medicare payment records. Demoz shared almost 1,800 of them with him over 18 months, the data show. Demoz and Genkin had about the same amount of patient overlap.

Mayura Kanekar is another Brooklyn provider who is part of the same circle.

Kanekar brought in nearly $3 million as the top Medicare-earning occupational therapist in the country in 2012. Occupational therapists work on people's fine motor skills so they can perform daily tasks. Over the 18 months covered by Medicare's referral data, a group of about 800 patients routinely visited both her and Khavash on the same day — seeing the two specialists back-to-back a total of 11,621 times.

None of the federal law enforcement officials USA TODAY interviewed would comment about whether any of the individuals are under investigation.

Kanekar said in an e-mail response that she doesn't refer anyone.

"Being serviced in a medical facility that is in close proximity to other specialties gives a patient the advantage of awareness and access to other specialties that can maintain their function and improve their quality of life," she wrote. "It would be wrong to assume and write that providers are 'circulating' patients within themselves."

Internist Demoz says he doesn't know the other providers, adding that doctors working in his three other offices may have done the referrals.

Khavash, who is also a registered nurse and is attending an online graduate school, says he had eight chiropractors working for him in 2012, but would not provide names.

He denies referring any patients to other specialists or getting any from others, which he says New York's Office of Professions prohibits. "We did see some patients that were common, but that is the benefit of having a practice in close proximity to a similar health care provider," Khavash said in an e-mail response.

Bakry and Genkin couldn't be found for comment.

Attempts to visit the addresses of many of the occupational therapists, physical therapists and chiropractors here who received the most from Medicare proved fruitless. The locations were either high-rise apartment buildings with no commercial presence or storefronts where new businesses had moved in. That also thwarted efforts to locate patients who are part of the referral networks.

RED FLAGS

Medical clinics are to Brooklyn what Starbucks locations are to other urban areas. And many of these offices seem to have a physical therapist, an occupational therapist or both.

When there are a lot of referrals among medical providers in a close area "with an extraordinary number of providers, that generally is a red flag," says the FBI's Casale.

It's illegal for doctors and other medical providers to give or get anything in return for a referral or to have a financial interest in an office they refer to, legal experts say.

Medicare fraud often involves kickbacks to other practitioners for referrals and specialists often reimburse patients for going in for tests or services they don't need, according to court documents and experts in the field. Patients — real or fake — allow medical offices to use their Medicare IDs to bill for these services and get money, gift baskets, massages or even computer classes in return.

Ralph Carpenter, director of Aetna's special investigations unit, says federal agents have conducted raids and found people whose homes all have the same big-screen TVs that were given in exchange for insurance ID cards. Such kickbacks are difficult for insurers to prove, so insurers and the Centers for Medicare and Medicaid Services work closely with law enforcement.

"This is an accepted practice and the beneficiaries are complicit in what's going on," Casale says. "They're not going to say, 'They gave me $100.' They are going to say, 'I was there and I did get this (service).'"

Other investigators say that as long as specialists are paid based on the number of services they perform — rather than whether they keep a patient healthy — fraud is a problem that isn't going away. And, as Bowerman notes, Medicare payments are "based on the assumption that claims are valid."

The government has limited resources and has to pick and choose what to pursue and tends to focus on cases that harm patients — like counterfeit drugs — and involve the largest-scale fraud, he says.

"I have reviewed cases that did not appear to be worth prosecuting, though on the surface appeared to be clear criminal misrepresentations," Bowerman says. "Providers can come up with substantial resources to defend fraudulent claims."

HARD TO FIND

The professional worlds of top Medicare money recipients — and referrers — in 2012 had in common a dingy medical center across from Coney Island's famous boardwalk.

Depending on the day, the changing cast of medical doctors and specialists may have included Bakry, Khavash and/or Genkin.

Until Hurricane Sandy swept through the clinic on Surf Avenue in October 2012, the 24 seats in the waiting room were always full, says Caesar Vitale, the building manager. The rest of the mostly elderly and nearly always Russian patients had to stand, he says.

A recent visit to the vacant office with Vitale showed something else that raises questions with legal experts: Two pedicure chairs of the type found in nail salons.

In several fraud cases Bowerman has worked on, medical clinics offered clients "spa services" like massage or personal training to lure them in and billed the services to government or private insurers with a medical diagnosis and codes for treatment.

Whatever services were being offered on Surf Avenue, there were a lot of them.

Bakry and Genkin were in the top 10 of nearly 825,000 practitioners in the country in the number of hours the work billed to Medicare in 2012 would have taken, according to MicroStrategy, a Virginia-based software company that has performed analysis on Medicare's data and built a mobile public health application.

The company looked at the types and numbers of procedures each practitioner billed and multiplied them by industry guidelines for how long each procedure takes to complete, and found that both men billed for more than 70 times the hours of the average specialist in their field.

Bakry's billing amounted to working more than 1,000 hours a week, assuming a 50-week work year, the analysis shows. Kanekar, also in the top 10, and Genkin each billed for roughly 500 hours a week of services provided, analysts found.

Kanekar says she had "11 licensed occupational therapy personnel working with me who saw patients and provided services" in 2012, but refused to provide contact information for them because it would be "unprofessional and unethical."

She also declined to provide a current office address and none could be found online.

Kanekar is listed in Medicare's database as working at the address of the Kingsbrook Jewish Medical Center in Brooklyn. The center's general counsel, Mike McDermott, says she only worked until 2009.

Genkin lists his office address online on 86th Street. In mid-May, a receptionist there said that he was expected to rejoin the group practice within weeks. As of Wednesday, Genkin still could not be reached there. It now includes practitioners in nine specialties, including physical therapy.

Missing offices are not unusual here. For example, another Brooklyn occupational therapist, Diana Cabana, is just as hard to locate.

Cabana is a former member of the Israeli army, horse trainer and dance instructor, according to a copy of her résumé posted on the website Indeed.com. In 2005, she was in South Florida working as the assistant sales manager of "Dollar Stores throughout the territory." Seven years later, after a stint as an occupational therapy intern, she received $1.2 million — the seventh highest amount for someone in her field in 2012. At the time she was working as an occupational therapist with general practitioner Paul Mathieu, her résumé says. Cabana did not respond to calls and texts seeking comment. Mathieu did not return calls either.

Cabana's address in the Medicare data is a ramshackle Brooklyn row house. The next-door neighbor of 10 years, who asked not to be identified because he said he didn't want to get involved, says the place has never housed any kind of medical professional or appeared to be visited by patients.

The Centers for Medicare and Medicaid Services has people who check out the addresses that practitioners provide when they sign up to accept Medicare, Casale says. Some medical providers fail to update the information on record about their practices. It doesn't necessarily mean it is what's known as a "false front" case where no medical practice is or was ever at the location, he says.

WHY BROOKLYN?

So why is Brooklyn a hot spot for certain pain-related specialties?

Some residents point to the densely populated area, which is easy to get around in and popular with many elderly people.

It also is a hot spot for the seriously ill — 27% of the borough's Medicare beneficiaries have six or more chronic conditions —- the highest rate in New York state, and nearly twice the national average. Diagnoses of diabetes, Alzheimers and heart failure are all particularly high in Brooklyn's Medicare population, data show.

However, in 2012, less than 7% of the borough's population received Medicare Part B benefits, which pay for medically necessary services and supplies to treat or prevent medical conditions, such as doctor visits, lab tests and wheelchairs. That's in line with the rest of New York City, but about half the average for the rest of New York state. Medicare is available to those 65 and older and younger people with disabilities.

Others point to the large population of elderly Russian people in the Brighton Beach area of the borough. After years of waiting in line for substandard and often corrupt medical care before coming to the U.S., many of these residents flock to the multiple choices of Russian doctors and therapists that surround them, says Yevgeniy Berenshteyn, a former Brooklyn occupational therapy aide who hopes to become a physical therapist.

"When they came here, they could get all this help and it's free, so why not?" says Berenshteyn. "If a doctor tells them to go see a physical therapist, they are going to take advantage."

Whatever the reasons for the high concentration of certain types of Medicare billing here, they combine to make it difficult for law enforcement to determine whether fraud exists. Tight-knit ethnic communities can be difficult to infiltrate, and the kind of ailment these therapists and chiropractors deal in — pain — is hard to disprove, legal experts say.

For example, take the case of Brooklyn family practice doctor Gustave Drivas. He was sentenced to 12 years in prison in September for his part in a scheme that fraudulently billed Medicare for more than $77 million.

Based on FBI wiretaps, prosecutors said Drivas was a "no show" doctor who allowed others to use his Medicare identification number to authorize claims for lab tests, physical therapy and other services that were either not needed or not performed.

In the Drivas case, patients were turned away if they weren't Russian and would line up outside a "kickback room" inside a facility, court documents show.

While prosecutors understandably focus more on fraud that harms consumers physically, Aetna CEO Mark Bertolini says Medicare, Medicaid and private insurance fraud is "not a victimless crime."

"In 2014, Americans will pay more than $80 billion for health care that was never delivered or never needed," he says. "It hurts real people, real patients, and reduces resources available to care for patients most in need."

Contributing: Yamiche Alcindor