Article: VSP Audits & Turning a Profit: Frequently Asked Questions

[AdminWolf]

You can view the page at http://www.odwire.org/forum/content/...sked-Questions

[Mike Sandy]

Brilliant article. Thank you, Dr. Steinberg.

[Kurt S. Petry O.D.]

Great article! I've been through 2 quality control audits, and done well each time. The last one was one occasion I was really glad to have an EMR - very simple and quick to print the exam reports, and the documentation level was well beyond what the auditors were used to seeing.

[Dr. Stanley Hallock]

You didn't mention that a targeted audit will demand repayment of billing related to plano opaque lenses because in VSP's opinion they are "non-prescription". Never mind that one needs an RX to get them. Long ago, Oracle Co. employees got an allowance of $800 for contact lenses. I had several patients electe to get many of virtually every color made so as to spend their entire allowance. Well VSP demanded all of that back a few years later.....with the threat being that if I didn't cough up the money, they would simply deduct that much from future checks. I don't take VSP these days.

[Tom Cheezum]

Thanks for your insight into this complex and intimidating process.

[Maurice Geldert, O.D.]

Dr. Steinberg has gone far beyond audit issues, and we will be using his article at staff meeting to be sure we are not only in compliance, but maximizing legitimate reimbursements in these economic times. May I mention in regards to EMR's to be sure ancillary visits and tests are printed when needed for audit compliance? For instance, if a contact lens P.E. is recorded separately from the primary/fitting exam, printing out the primary will not show you to have performed any follow-up, and you will have this noted by VSP, something we discovered after changing from one EMR to another. After receiving the report, I went through records, found all follow-up visits, sent these (unrequested by VSP) in, and advised them of name of EMR, in hopes of helping others avoid future problems. We are currently going through 90 MU qualifications, and all of us are constantly barraged by changes in requirements, regional inconsistencies in regional Medicare policies, etc., and articles such as these provide great resources. Thank you!

[Jonovan Ottenbacher]

Excellent article! I have a couple of questions related to EHR, though: (1) You mention that I&R reports must be a separate document. However, many EHR systems have a section for additional testing, such as visual fields, photos, etc on the main exam form, and I&R can be entered there. Does VSP actually want doctors to create a new exam just for the I&R in addition to the main exam and not use the section in the patient's main exam for that day? (2) Regarding default values, if a doctor find something not normal, should s/he delete the default statement as well, or is it OK to leave it there? I.e, does additional information automatically override the default values or will VSP argue it's conflicting information? It's just a pain looking for, selecting, and deleting any default statements in addition to noting it every time I see something not normal. Thanks!

[Larry Terry]

I just began using officemates examwriter in my office and have a question regarding special testing requirements for a separate identifiable interpretation and report. Examwriter has this structured within the exam. If I perform an exam (either 99--- or 92---) on the same day as a test such as threshold fields is it allowable (for VSP and Medicare) to have the interpretation and report within that days exam under the special testing area?

[Jil Klein, O.D.,F.A.A.O.]

Wow! This is a wealth of excellent information you have so clearly shared with us all. I know my practice is a bit unusual because I take very few vision management plans and decided not to participate in VSP or Davis for that matter because they are too much into our businesses and control optometry, but I will add, for me, the info you presented in general holds true for medical insurance plans and smart practice protocols. Thanks!

[Godwin Ekekhomen]

An excellent piece of work which every Optometrist that takes insurance should read, Not just VSP

[Steve Shum]

comment and question. Thanks for the excellent synopsis of VSP audits. Compulink EHR has tabs for supplemental testing that include areas for interpretation and reports. Would these separate tabs be considered adequate for adherence to VSP I & R rules? thanks again, Steve Shum

[Teresa Chang]

Great article!! Thank you!

[David W Miller]

But....., but......., but........, VSP is our FRIEND, right!??!?!?

[Steven Nelson]

I find it interesting that despite being a vision plan, not only are they aggressive about initiating audits, but go for the throat. You just don't hear that much from medical plans. Is it my imagination or am I just missing something?

[Raymond Z Huang]

Have been through VSP Target Audit in our office, this is an excellent article. May I add to make sure all document and record are to be signed and dated, or VSP would deem it as non-compliance, and not official record. In addition, when patient pick up any VSP provided items, has patient sign and date on the record for the items, and make sure they are in the patient record. Our office was audited, and was penalize for no record of patient receiving the items. Although we have patient to produced sworn affidavite in regard to receiving the items, but VSP still demand repayment for all records without patient signature and date.

The "fair hearing" process can be done in person or via phone conference. The date and time are pre-determined, however, dont expect to have the entire alloted time to be granted. The time frame given is only for you to know they will take your case at that time interval, and they can terminate it at any time the panel determine no further time needed for them to render their decision. Be prepare with all supplement documents, but more than likely they are not going to change much about the amount of restitution.May I also add, some plan has benefit for covered contact lens where the patient's one-year supply of contact lenses related services are covered. This is also an area where VSP do consider as a highly audited area. Plano color contact lenses, or RX of +/-0.25D will definitely be deny upon audit process, because they dont meet the minimum RX requirment. Patient whom are qualified for this benefit are entitle to one-year supply of lenses, however, VSP may not pay enough for the year supply of lenses, but the office is still under the obligation to produce complete year of lenses. Therefore, choose to accept the plan wisely, otherwise you can give patient the contact RX, and ask him to get it somewhere else.

Just a footnote, have been survive the complete targeted audit, Restitution, Appeal, and Probation process, we have instituted numbers of procedures to minimize the possibility of violation. However, if VSP has targeted your office for any violation, more likely, they will certain to want to get restitution from you whether you are in full compliance or not. As previous article has mentioned, VSP has step up their audit in recent year, and it has been a money maker for them.

[Jeff Eger]

Great article.What % of cases on VSP do you win for your client?I never had a malpractice suit,but my fees are high for keratoconus ,ortho-k,and fitting abnormally shaped corneas.In a town where I practiced one OD had 2 malpractice cases(one misdiagnosing glacoma) yet was never removed off VSP panel or recorded in state boards as having a complaint today.I was removed from VSP in 1984 and submitted a plan of action.They took me off VSP without a reason.Do you handle discrimination cases?What has been your success when it is politically bent?I have spent almost one year reapplying and it is one excuse after another why all my forms and apps have not been sent.They have.drjeffeger@cox.net

[J Ruff]

This has been a very enlightening topic. One that has finally given me the courage to drop VSP. As of this moment, I personally took my termination letter to the post office and sent it out Priority mail. I will not be a slave to this organization. They are absolutely unreasonable and abusive. Who are they to tell us what docs need to be signed by whom and when and for what and what to charge and what test to perform, etc!! Did we not go to school for 8 years, passed our Boards (which ever), receive a license and insurance credentialling and for what? To be dictated to with fear of an audit for a measlly $50-60 for a comprehensive exam, refraction, dfe??No Thank You, VSP.

[Richard_Hom]

Knowing that there are "onerous" requirements to continue with Vision Service Plan (VSP), the requirements for Medicare are also noteworthy formidable. When the Medicare cut comes (20-25%) would you also quit Medicare in light of their equally constraining audit requirements?

[J Ruff]

Knowing that there are "onerous" requirements to continue with Vision Service Plan (VSP), the requirements for Medicare are also noteworthy formidable. When the Medicare cut comes (20-25%) would you also quit Medicare in light of their equally constraining audit requirements?

Richard. I don't know. Guess I 'll cross that bridge when u come to it. For now...see the smile on my face

[Stephen McDaniel]

Knowing that there are "onerous" requirements to continue with Vision Service Plan (VSP), the requirements for Medicare are also noteworthy formidable. When the Medicare cut comes (20-25%) would you also quit Medicare in light of their equally constraining audit requirements?

Having read both the Medicare and VSP contracts several times, IMO the VSP contract is considerably more "onerous". I honestly think the VSP contract is written in such a way so that compliance is not possible. The difference mainly is VSP's attempt to control every aspect of your business and the ridiculous rules for documenting the dispensing of materials. As an example of how absolutely insane VSP is, you are not allowed to refer a patient to an out-of-network LASIK surgeon. Think about that for a second.........the ethical implications are enormous.

[Stephen G. Hlis, O.D.]

Having read both the Medicare and VSP contracts several times, IMO the VSP contract is considerably more "onerous". I honestly think the VSP contract is written in such a way so that compliance is not possible. The difference mainly is VSP's attempt to control every aspect of your business and the ridiculous rules for documenting the dispensing of materials. As an example of how absolutely insane VSP is, you are not allowed to refer a patient to an out-of-network LASIK surgeon. Think about that for a second.........the ethical implications are enormous.

Where does the 800lb gorilla sit? Where ever he wants. These are consequences of being in bed with the devil.

[Jonathan Warner]

Where does the 800lb gorilla sit? Where ever he wants. These are consequences of being in bed with the devil.

Now that's a good one!

[Ken Bova]

This has been a very enlightening topic. One that has finally given me the courage to drop VSP. As of this moment, I personally took my termination letter to the post office and sent it out Priority mail. I will not be a slave to this organization. They are absolutely unreasonable and abusive. Who are they to tell us what docs need to be signed by whom and when and for what and what to charge and what test to perform, etc!! Did we not go to school for 8 years, passed our Boards (which ever), receive a license and insurance credentialling and for what? To be dictated to with fear of an audit for a measlly $50-60 for a comprehensive exam, refraction, dfe??No Thank You, VSP.

That is a most courageous thing that you have done dropping VSP. Now you must relize that those patients on VSP will not be coming to you any longer, probably 100% of them. No, I would not have the nerve to drop VSP under those circumstances. In this society, you must take the good with the bad.

[Stephen McDaniel]

You're my hero Dr. Ruff. Congrats!

I'll disagree with Ken. Depending on your area and your patient repoir, you'll retain 10-50%. Get real good at figuring out how to admin out-of-network for VSP and real good at convincing patients the value of your continued services and you can get closer to that 50% all the while not having VSP breathe down your neck. I've read here many docs brag about their increased net after dropping VSP and not one regret. I hope to garner your same courage in the coming years. Please keep us updated along the way.

[J Ruff]

Wow thank you for the encouragement. I really appreciate it. I don't see many VSP pts so I don't anticipate a significant change. I just can't accept the idea of them walking in one day demanding charts; that's unfair and unreasonable. I dont have a thing to hide but seriously, thats equivalent to a holdup.

We recently requested a fee increase since I haven't had one since purchasing my practice 4 yrs ago. It was declined. Here was the response I received from an area VSP rep:

"Well, I did not get the answer either of us was hoping for. The reply from VSP is pasted below. FYI: LOB means "lines of business' and refers to VSP Labs, Altaire, Marchon, Eye Designs, and Officemate. Remember, if you check the Eye Health Management boxes when you file a claim you get an extra $2-$5, depending on which box gets checked. In the letter there is mention of an "opportunity calculator." I will attach it.It shows the various ways that you can increase what you make from VSP is to use their labs and products. (Like Unity and Reveal lenses) Remember that in my office Coordination of Benefits is a major way to increase fees. We have been over that but feel free to call with questions any time.

'We just had our meeting with executive management to discuss Dr. Ruff's fees. A request for a payable increase was unfortunately denied. Some of the comments as to why included the following:
- VSP is currently under a Board of Directors mandated fee freeze in order to control costs and remain competitive in order to continue pumping patients thru our panel doctors' doors.
- VSP has been under increasing pressure to deliver competitive rates to our clients because other vision plans such as EyeMed are able to deliver lower prices. Other vision plans do so by paying lower reimbursement to doctors so they in turn can charge the client less. Doctors on VSP who choose to accept lower reimbursements from other plans hurt our ability to increase our reimbursements.
- VSP, in general, is unable to provide fee increases due to competitive concerns, but are looking for ways to deliver more dollars to practices when they use our LOBs. '

I don't know if this will help, but I've also attached the practice's opportunity calculator, which shows some of the revenue generating potential of using our products for lens options & upgrades. The office will be sent a letter in the mail highlighting this information as well. Please let me know if you need any additional info, or have any questions. Thanks. "

Basically, they want us to use their labs, frames, lenses, blah blah blah. Oh and we get chastised for accepting other vision plans. And after all this, we get a chance to be subjected to an unannounced audit at their discretion. Forget about it. Stick a fork in me, I'm done.

I hope others will be encouraged to drop them. It's certainly not a decision to be taken likely. I will keep you all posted.

Again, thanks.

[Jonathan Warner]

Wow thank you for the encouragement. I really appreciate it. I don't see many VSP pts so I don't anticipate a significant change. I just can't accept the idea of them walking in one day demanding charts; that's unfair and unreasonable. I dont have a thing to hide but seriously, thats equivalent to a holdup.

We recently requested a fee increase since I haven't had one since purchasing my practice 4 yrs ago. It was declined. Here was the response I received from an area VSP rep:

"Well, I did not get the answer either of us was hoping for. The reply from VSP is pasted below. FYI: LOB means "lines of business' and refers to VSP Labs, Altaire, Marchon, Eye Designs, and Officemate. Remember, if you check the Eye Health Management boxes when you file a claim you get an extra $2-$5, depending on which box gets checked. In the letter there is mention of an "opportunity calculator." I will attach it.It shows the various ways that you can increase what you make from VSP is to use their labs and products. (Like Unity and Reveal lenses) Remember that in my office Coordination of Benefits is a major way to increase fees. We have been over that but feel free to call with questions any time.

'We just had our meeting with executive management to discuss Dr. Ruff's fees. A request for a payable increase was unfortunately denied. Some of the comments as to why included the following:
- VSP is currently under a Board of Directors mandated fee freeze in order to control costs and remain competitive in order to continue pumping patients thru our panel doctors' doors.
- VSP has been under increasing pressure to deliver competitive rates to our clients because other vision plans such as EyeMed are able to deliver lower prices. Other vision plans do so by paying lower reimbursement to doctors so they in turn can charge the client less. Doctors on VSP who choose to accept lower reimbursements from other plans hurt our ability to increase our reimbursements.
- VSP, in general, is unable to provide fee increases due to competitive concerns, but are looking for ways to deliver more dollars to practices when they use our LOBs. '

I don't know if this will help, but I've also attached the practice's opportunity calculator, which shows some of the revenue generating potential of using our products for lens options & upgrades. The office will be sent a letter in the mail highlighting this information as well. Please let me know if you need any additional info, or have any questions. Thanks. "

Basically, they want us to use their labs, frames, lenses, blah blah blah. Oh and we get chastised for accepting other vision plans. And after all this, we get a chance to be subjected to an unannounced audit at their discretion. Forget about it. Stick a fork in me, I'm done.

I hope others will be encouraged to drop them. It's certainly not a decision to be taken likely. I will keep you all posted.

Again, thanks.

I am not happy with VSP either and have written them letters explaining my concerns. But they have a point in the bolded statemment above. ODs are undermining VSP and in doing so, undermining themselves also.

[Stephen McDaniel]

I am not happy with VSP either and have written them letters explaining my concerns. But they have a point in the bolded statemment above. ODs are undermining VSP and in doing so, undermining themselves also.

You're wrong. To use your favorite quote against you, you have partaken of the kool-aid.

[Jonathan Warner]

You're wrong. To use your favorite quote against you, you have partaken of the kool-aid.

Stephen,

Perhaps you had a mini-stroke.

When a doc signs up for a VCP that pays less than VSP, the VCP can underbid VSP because it can pay it's contracted docs less than VSP is paying theirs. Thus continues the race to the bottom. What is it you don't understand about that?

[Stephen McDaniel]

Stephen,

Perhaps you had a mini-stroke.

When a doc signs up for a VCP that pays less than VSP, the VCP can underbid VSP because it can pay it's contracted docs less than VSP is paying theirs. Thus continues the race to the bottom. What is it you don't understand about that?

Jon are you the cheapest OD in your town? No? Yet patients still come and see you. When you compete on price you live and die by price. VSP had plenty of opportunity to sell themselves to Companies and providers alike focusing on their many PREVIOUS positive non-price oriented attributes. VSP has no one to blame but themselves and it's high time you recognize that. The blame shifitng PR nonsense is nothing more than damage control.

[Jonathan Warner]

Jon are you the cheapest OD in your town? No? Yet patients still come and see you. When you compete on price you live and die by price. VSP had plenty of opportunity to sell themselves to Companies and providers alike focusing on their many PREVIOUS positive non-price oriented attributes. VSP has no one to blame but themselves and it's high time you recognize that. The blame shifitng PR nonsense is nothing more than damage control.

Stephen,

Unfortunately, in today's world, businesses are making their decisions about which VCP to choose based on price and not much else. That is why the bottom feeding VCPs are winning contracts previously held by better paying plans.