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One Therapist, $4 Million in 2012 Medicare Billing

A few miles from the Coney Island boardwalk in Brooklyn stands an outpost of what, on paper, is a giant of American medicine.

Nothing about the place hints at the money that is said to flow there. But in 2012, according to federal data, $4.1 million from Medicare coursed through the office in a modest white house on Ocean Avenue.

Wael Bakry says he has not worked out of his Ocean Avenue office for years — but his billings are attributed to the address.
Robert Stolarik for The New York Times
Wael Bakry says he has not worked out of his Ocean Avenue office for years — but his billings are attributed to the address.

In all, the practice treated around 1,950 Medicare patients that year. On average, it was paid by Medicare for 94 separate procedures for each one. That works out to about 183,000 treatments a year, 500 a day, 21 an hour.

What makes those figures more remarkable, and raises eyebrows among medical experts, is that judging by Medicare billing records, one person did it all. His name is Wael Bakry, and he is not some A-list cardiologist, oncologist or internist. He is a physical therapist.

But physical therapy, it turns out, is a big recipient of national Medicare dollars — and physical therapy in Brooklyn is among the biggest of all. Of the 10 physical therapists nationwide who were paid the most by Medicare in 2012, half listed Brooklyn addresses, according to an analysis of Medicare billing data by The New York Times. Two others listed addresses on Long Island, one in Queens, and one each in California and Texas.

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Mr. Bakry, 42, did not dispute the $4.1 million figure. But he said that the Medicare data, released to much fanfare this month, could be "deceiving." One person, he said, could not provide all of that care alone.

"I'm not Superman," Mr. Bakry said.

One thing is certain: Physical therapy has become a Medicare gold mine. Medicare paid physical therapists working in offices $1.8 billion in 2012 alone, the 10th-highest field among 74 specialties, according to the Times analysis. In Brooklyn, physical therapy was second only to internal medicine.

Why Brooklyn? Federal authorities say the borough is a national hot spot for Medicare fraud, particularly fraud involving physical therapy. Unscrupulous practitioners bill Medicare for unnecessary treatments or procedures they never perform — something that is often easier to do in physical therapy than in fields like oncology or cardiology.

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While some experts have expressed skepticism about Mr. Bakry's numbers, he said Medicare had never questioned his billing practices nor denied payments to his practice. Mr. Bakry does not appear in a database of providers who are currently excluded from the Medicare program.

Perhaps most of this Brooklyn story illustrates how medical treatments vary wildly from region to region, state to state, and — at times — even neighborhood to neighborhood. Physical therapists in Brooklyn tend to bill Medicare patients for more treatments than their counterparts elsewhere in country — and even elsewhere in New York City. On average, they billed each patient for 45 separate treatments in 2012, the Times analysis found. Across the river in Manhattan, the average was 37. In Connecticut, it was 24, while in Minnesota, it was a mere 13.

Mr. Bakry offers an explanation echoed by other practitioners: the newly released Medicare data paints an incomplete picture of where taxpayer dollars are actually flowing. In an interview, Mr. Bakry said his practice had about two dozen physical therapists and assistants working in four offices in 2012. The care provided by all of those therapists and assistants went under his Medicare billing number because he owned the practice.

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While Medicare has encouraged providers to bill under their own numbers, the agency acknowledges that data for some providers covers multiple practitioners. Mr. Bakry said he could never himself have provided all the treatments the data appears to suggest.

Furthermore, Mr. Bakry, who says he now operates three offices in different locations in Queens, says he has not worked out of the Ocean Avenue office for years — even though the Medicare data attributed his billings to that address.

"I don't know why they keep using that address," Mr. Bakry said.

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The release of the 2012 billing records this month set off a firestorm in the medical community. Many applauded the move, saying it shed light on the costs of health care and gave ordinary people a way to compare doctors and treatments.

But the American Medical Association and other industry groups fought against the release of the information. (The Obama administration released it after a long legal battle led by The Wall Street Journal.) The A.M.A. and its allies argued that the raw data provided patients with no information on quality of care.

And for practitioners like Mr. Bakry, who found themselves at the top of highest-billers list, the data thrust them into an uncomfortable public spotlight.

Whatever the case, as the nation's population ages and increasingly gets knees, hips and other joints repaired or replaced, demand for physical therapy treatments has been on the rise — and so has fraud. Billing for physical therapy services has come under heightened scrutiny by regulators and law enforcement in recent years, leading to numerous crackdowns and raids of physical therapy clinics around the country, including Brooklyn.

Those enforcement efforts have yielded big results. In 2011, a Brooklyn physical therapist pleaded guilty to submitting nearly $12 million in false and fraudulent claims to Medicare over more than five years. Last year, the owner of a Brooklyn medical clinic was sentenced to 15 years in prison for her role in a $77 million fraud in which patients were paid cash kickbacks to induce them to remain silent about services, including physical therapy, that were not provide, but were billed to Medicare.

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On average, physical therapists collected about $49,000 in Medicare payments in 2012, according to the data. Those reaping much more caught the eye of many experts scouring the data.

"The billing of some of these outliers — the thousands of hours of care that was provided — is it feasible to even bill that much service in a calendar year?" said Justin Moore, the vice president for public policy at the American Physical Therapy Association, which is doing its own analysis of the Medicare data and also noted the disproportionate number of high billers from Brooklyn.

"Even the ones who are billing hundreds of thousands of dollars start to raise some caution for us," Mr. Moore said.

Experts also expressed skepticism about the high number of treatments Mr. Bakry and other physical therapists in Brooklyn were providing their patients.

The 94 treatments Mr. Bakry's average patient received during the year were more than three times the national average. The second-highest biller in the country, which Medicare also listed under a Brooklyn address, also provided 94 treatments a patient, while the third-highest payee, yet another Brooklyn therapist, provided an average of 82 procedures a patient.

Mr. Bakry, noting that a physician must first approve a plan of treatment by a physical therapist before the therapist can be reimbursed, said that he stretched the patients' procedures over many visits and that he was doing what was needed to improve his patients' health.

While it has long been recognized that there are huge disparities between regions concerning the numbers of Medicare procedures performed, there is no consensus on why the disparities exist.

"An area like physical therapy is a bit gray because there's no set guideline on how much a given patient needs," said Jonathan S. Skinner, an economics professor at Dartmouth who has studied geographic variations in health care. "In some of those cases, the differences in level of services might be explained by where you find more entrepreneurial physicians."

At Mr. Bakry's practice, not only did the 1,950 patients receive high numbers of procedures, but almost all of the Medicare beneficiaries were billed for an initial evaluation and the same four treatments — electric stimulation, massage therapy, therapeutic exercises and therapeutic activities.

Experts say that consistency is unusual.

"Generally, physical therapists take a lot of pride in the individualized nature of their care, and to do something at that sort of consistent level seems like a very uniform treatment plan for every patient," said Mr. Moore of the American Physical Therapy Association.

Mr. Bakry said he had developed a treatment protocol for his older patients that he had taught to the therapists he employs.

As for the high number of treatments his patients receive, Mr. Bakry said that because they receive good care, they return when they have other problems.

"Sometimes they come in for a problem with their shoulder and they have 10 or 12 sessions and they feel fine, and then they come in for another problem, maybe with their knee," Mr. Bakry said. "If the patients didn't get the good care, they wouldn't come back to us again."

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