This story is part of an investigative series by 番茄社区 and the Milwaukee Journal Sentinel into physicians who had public actions against their licenses in one state, yet found ways to keep practicing without their patients being aware.
Physicians who land in hot water with state regulators have a helping hand when it comes to keeping their practices running:
The federal government.
At least 216 remained on Medicare payment rolls in 2015 despite surrendering a license, having one revoked, or being excluded from state-paid healthcare rolls in the previous five years, a 番茄社区/Milwaukee Journal Sentinel investigation found. In all, they were paid $25.8 million by taxpayers in 2015 alone.
Among them: Glen Marin, DO, from New York City.
According to New York Department of Health disciplinary records, Marin that he was sexually inappropriate with a female patient. In California, as a result, he rather than go through a full disciplinary hearing.
He was allowed to keep practicing in New York, but only if he had a chaperone present when he met with female patients.
Since 2007, Marin settled at least three separate malpractice cases, according to TruthMD, including one for the cancer that eventually killed a patient.
Despite that, taxpayers helped foot the bill for him to keep practicing medicine. In 2015, the year after he surrendered his California license, he was paid more than $280,000 through Medicare.
Other individual physicians who faced serious sanctions were paid as much as $1.4 million that year.
The analysis focused on 2015 because that is the last year for which payment details from the annual $720-billion Medicare program are available.
To identify these cases, reporters from the Milwaukee Journal Sentinel and 番茄社区 worked from a list compiled by TruthMD, a Los Angeles-based company that collects information on physicians from state boards, courts and other sources. The news organizations focused on the most serious cases -- those in which physicians were stripped of their ability to practice or barred from state-run healthcare payments -- then compared those names to Medicare payment data to gauge the total cost of looking the other way.
Medicare is part of the U.S. Department of Health and Human Services (HHS) -- the same department that operates the National Practitioner Data Bank, which tracks discipline against physicians, including sanctions by state medical boards.
"That's astonishing to me that HHS allows that to happen," said Michael Carome, MD, who heads the watchdog group Public Citizen's healthcare division. "If someone has a pattern of such adverse actions, that ought to be a red flag."
Attempts to reach Marin were unsuccessful. His profile on the shows that he is now retired, but retains hospital credentials. The website says prospective patients can "contact the doctor's office to see if this doctor is taking new patients."
He did not return messages left at offices associated with his practice.
The HHS Office of the Inspector General (OIG) is required to exclude physicians from payment rolls if they are convicted of several specific charges, such as abusing patients, defrauding the system, or are caught improperly prescribing controlled substances.
But there are 16 categories of problems where the OIG may choose not to exclude physicians, including failing to meet basic standards of care or even having a medical license revoked.
As a result, while more than 1,500 physicians had licenses suspended, revoked or put on probation in 2015 by state medical boards, only 305 were prohibited from billing Medicare that year.
George Annas, JD, MPH, a professor of health law and bioethics at Boston University, said Medicare is enabling bad physicians to continue practicing.
"The last thing you want is Medicare patients to be seeing the worst doctors in the country," said Annas, who spent six years on the medical board in Massachusetts. "That's not right. They should be protecting Medicare patients. That should be their number one job."
HHS databases
The Journal Sentinel and 番茄社区 were able to find examples by simply comparing two kinds of information that HHS already maintains.
That turns up physicians such as Victoria Gaus, MD, who practices in Florida.
In 2012, the Florida medical board said -- opioids and tranquilizers -- to five patients. That same year, a $50,000 malpractice claim was submitted to the Florida Office of Insurance Regulation involving a patient who died of an overdose.
In 2013, Gaus agreed to a reprimand, a $20,000 fine, a permanent ban from practicing in a pain management clinic, and a permanent ban from prescribing certain opioids drugs as well as a type of tranquilizer known as benzodiazepines.
She did not lose her license in Florida, but Illinois refused to renew her license based on the Florida action and Pennsylvania indefinitely suspended her license.
In 2015, Medicare paid her a total of $60,000. Gaus could not be reached by phone or email, and did not respond to a certified letter.
The review also turned up David Martini, MD, who practices in Maryland.
In 2013, , but put no restrictions on his license, after allegations that he performed back and abdominal liposuction on a woman who died as a result of the procedure. Martini is an ear, nose and throat specialist who was not trained in plastic surgery of the body, according to an anonymous complaint filed with the Maryland Board of Physicians. The board eventually found that Martini failed to properly supervise a nurse anesthetist and that he violated the law by performing the liposuction in his office which was not an accredited facility.
Based on Maryland's action, Martini permanently surrendered his licenses in New York and Pennsylvania in 2014.
In 2015, he received $272,000 from Medicare. Martini would not comment for this story.
And Sarkis Aghazarian, MD, a surgeon who also practices in Maryland.
In 2003, in a case in which he allegedly failed to diagnose and treat a serious infection that led to a man's death.
In a 2011 malpractice lawsuit, he was accused of the 2008 death of a 70-year-old Maryland man after complications arose following an angioplasty he performed.
In each case, Aghazarian paid settlements of $250,000. He says he did so because it was cheaper than going to trial.
In 2012, a Maryland hospital suspended him for 90 days after complaints that included abusive language, angry and intimidating behavior, and rudeness in the operating room toward staff members and patients -- in one case yelling at a woman while she was on the operating table.
In Maryland, the allegations led to a Based on Maryland's case, California took action that led to the surrender of his license there in 2014.
In May 2015, Aghazarian's and he was paid $321,000 that year from Medicare.
In an interview, Aghazarian said Medicare has reviewed his record and allowed him to continue seeing those patients.
"I never mistreated any of my patients," he said.
He said the allegations that he was abusive and disruptive in the hospital were "pure dirty politics" that came about because he complained about patient safety.
"Rather than fixing the problems, they labeled me as disruptive," he said. "I was trying to protect patients."
More protections in private sector
Private insurance companies spend money to make sure they don't pay more than needed, or support bad medicine, said Leslie Paige, vice president for policy and communications for Citizens Against Government Waste, a nonprofit watchdog group that lobbies for reduced government spending.
Medicare doles out far more money and isn't even using the data the department already gathers on physicians' problems, she said.
"They need to do a better job of tracking these people down and stopping them before they abscond with taxpayer dollars or hurt patients," Paige said. "Seniors should not be sitting ducks for predators simply because they're on Medicare."
One example: James McGuckin Jr., MD, the target of a Washington state investigation and an FDA letter into his use of a risky and unproven vein-opening procedure on people with multiple sclerosis. McGuckin was part of an earlier Journal Sentinel/番茄社区 investigation that found states were slow to take action against physicians who performed the procedure.
In a statement to an evaluator for an ethics course that was required as part of his Washington state discipline, McGuckin noted that several private insurers had cut ties with him.
But he has not lost his license and is still eligible for payments from the Medicare system. In 2015 alone, he was paid $8.8 million, the 番茄社区/Journal Sentinel analysis found.
According to Todd Echols, who oversees the OIG's program, workers managing exclusions can be overwhelmed by a flood of information about providers -- in part because computers are now involved.
For decades, the process was driven through relationships investigators forged with state medical boards. The state boards kept an eye out for cases that fit the criteria for exclusion from the federal system, then passed them along.
Last year, OIG started getting a data feed from the Federation of State Medical Boards. In the first year alone, the group sent more than 2,000 cases to investigate. The actions were a mix of positive and negative, and the vast majority didn’t meet the criteria for federal exclusion, a spokesman said.
"We can't get through 2,000," Echols said. "There are some actions that we just don't even have a chance to get to."
There's also a good chance his inspectors couldn't take action in many of those cases.
Some exclusion authorities only come into play if a physician's behavior affected a patient on Medicare or Medicaid.
Echols said documents in such cases -- whether they be from state medical boards, court filings or other sources -- have to clearly indicate a relationship to those one of those two programs.
The problems must also match those in the federal law describing the exclusion process. For example, they have to document issues with "professional competence" or "financial integrity" to result in an exclusion.
"We have seen variation across the country as to when a licensing board will take action," Echols said. "They know if they put these actions in there, it's going to hurt [physicians]."
Echols said his investigators pursue cases that demonstrate a physician is dangerous or fraudulent, not merely incompetent.
Consider Lindsay Brathwaite, MD, a dermatologist in Delaware.
According to medical board filings from Delaware and California, Brathwaite ran an office in Delaware, where . He didn't use diagnostic tests or sterilize instruments. His office had open bottles with needles in them and allowed for cross-contamination of blood products.
"Respondent exposed patients to the possibility of contracting hepatitis, AIDS and other blood-borne pathogens," said a complaint filed by Kimberly Kirchemeyer, executive director of the Medical Board of California, where Brathwaite also had a license.
Two of the three states where he was licensed revoked his privileges in 2015.
That year, Medicare still paid him $100,000 to treat seniors.
He was prevented from receiving money through the program in May 2016.
"We take our time, we're really careful," Echols said. "We want to make sure we're excluding physicians that deserve to be excluded."
Still waiting
Federal regulators have not excluded operating in the Detroit suburbs.
His office, Compassionate Doctors, purported to be a physician's practice. In actuality, "marketers" paid people to pose as patients, who then received fraudulent prescriptions for controlled substances, mostly opioid painkillers. The drugs were then sold on the streets.
According to federal charges following his 2013 arrest, Pamatmat illegally prescribed 200,000 dosages of oxycodone, and 1 million units of hydrocodone. All told, he was behind $4 million in healthcare fraud between 2009 and 2013.
Pamatmat was arrested in 2013 and barred from Michigan's federally-funded Medicaid program for low-income patients. While on bond, he was ordered not to prescribe controlled substances.
Federal records show he kept right on doing so. Medicare underwrote prescriptions he gave out for tranquilizers and amphetamines after his arrest.
In 2014, taxpayers paid him $114,000; the next year, $118,000.
Last May, he was sentenced to 19 years in prison and is currently behind bars.
His name still does not appear on the list of physicians ineligible for Medicare payments.