Mr. Lauder’s original complaint also noted a retinal drawing must be maintained in the patient’s record, and the drawings should include sufficient detail, standard color and appropriate labels. CPT mandates an interpretation and report which includes, at a minimum, the physician’s findings and impression. The original complaint did not specifically say Dr. Davitt was not submitting the required documentation.
Dr. Bradley Davitt was not surprised to learn he has a statistically high number of billings under the 92225 and 92226 designations as he one of the few doctors in the region qualified to do so. He is the Director of Paediatric Ophthalmology for Cardinal Glennon Children’s Hospital, specializing in the screening and examination of premature infants for “Retinopathy of Prematurity (RP)” and provides the same services for St. Mary’s Hospital in Jefferson City, Southeast Missouri Hospital in Cape …show more content…
Girardeau and provides coverage for Mercy Hospital in Creve Coeur. All exams and scheduled follow-ups are based on recommendations made by the American Academy of Paediatrics.
Because Aetna was unable to provide specific cases to review Dr. Davitt had no further information to add but states he will be happy to cooperate with BHA and answer any questions provided.
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DETAILS OF INVESTIGATION
Phone Interview of Steven Lauder, Investigator for Aetna Insurance, 9900 Corporate Campus Dr, Louisville, KY 40223 (502) 719-8579
I called Mr. Lauder on two occasions, leaving voice mails both times but received no response. Prior to closing out the report I phoned Mr. Lauder again July 25, 2016 and was able to reach him.
Mr. Lauder stated the following: The referral is not based on case audits of specific patient files, but rather an unusually high number of patients billed under billing code 92225 and 92226 in the region. He was aware Dr. Davitt was a Pediatric Ophthalmologist, but noted statistically Davitt billed for more initial screening (92225) and follow-up screenings (92226) than other Pediatric Ophthalmologists in the St. Louis area.
I informed Mr.
Lauder of Dr. Davitt’s affiliation with Cardinal Glennon Hospital as Director of Pediatric Ophthalmology, and his additional coverage for St. Mary’s Hospital in Jefferson City, Southeast Missouri Hospital in Cape Girardeau, and Mercy Hospital in Creve Coeur, Missouri. Mr. Lauder said based on Dr. Davitt’s position with Cardinal Glennon Hospital and the number of other Missouri hospitals he provides services to, the high number of patients seen made sense, so there appeared to be no issues for this provider. Mr. Lauder did want to note that their current policy says any statistical anomalies should be referred to individual states Departments of Insurance for review and
follow-up.
I reminded Mr. Lauder that his original complaint noted “retinal drawing must be maintained in the patient’s record, and the drawings should include sufficient detail, standard color and appropriate labels. CPT mandates an interpretation and report which includes, at a minimum, the physician’s findings and impression” but didn’t note it as a complaint. Mr. Lauder reviewed his notes and said there were no issues stated for documentation and the sectional was for informational purposes only.
Interview of Dr. Bradley Davitt, Cardianl Glennon Hospital, 1465 South Grand Blvd, St Louis MO (314) 577-5660
Dr. Davitt was interviewed at his business offices on June 14, 2016 and stated the following: Dr. Davitt holds the position of Director of Paediatric Ophthalmology, specializing in the screening and examination of premature infants for “Retinopathy of Prematurity (RP)”. He was unaware of any concerns or questions from Aetna Insurance.
His office assistant reviewed files from July 2015 thru June 2016 and noted he did 132 initial eye exams for RP and 403 follow-up eye exams for Cardinal Glennon alone. He is not surprised to learn he has a statistically high number of billings under the 92225 and 92226 designations as he one of the few doctors in the region qualified to do so, and all exams and scheduled follow-ups are based on recommendations made by the American Academy of Paediatrics.
Dr. Davitt noted RP was a leading cause of blindness for premature infants. His primary duties at Cardinal Glennon are to screen for RP and provide treatments to “preemies” born at or transported to Cardinal Glennon Hospital. He is also in charge of providing the same services for St. Mary’s Hospital in Jefferson City, Southeast Missouri Hospital in Cape Girardeau and provides coverage for Mercy Hospital in Creve Coeur.
Dr. Davitt submitted a policy statement published by the American Academy of Paediatrics titled, Screening Examination of Premature Infants for Retinopathy of Prematurity dated January 2013 ( see attachment #1).
Dr. Davitt says the hospitals “Compliance Unit” did its own internal audit approximately February 2015 for billing purposes. He noted there were changes in documentation sent to insurance providers. In retrospect he felt it may have been in response to Aetna’s assertion they weren’t receiving appropriate documentation with billing invoices but doesn’t know for sure.
Dr. Davit stated he would be happy to discuss the issue with BHA or insurance providers as necessary to clear up the matter, but can add little more without case specifics.