Generally, VSP has two kinds of audits. 

Quality Control Audits

The first is common and is known as a "quality control audit." These are generated by the quality control department (not their fraud prevention department) and are routine in nature. Most doctors should expect one of these audits every 3-5 years. VSP will request that you send in the records for 10 specified patients. They then review these records for general compliance with VSP quality control rules. They look for correct calculation of fees, collecting co-pays, exams being complete, and other routine quality control matters. If problems are found you may be required to refund some money to a patient, or to VSP, and you may be required to have another audit in six months. 

SIU/Fraud Audits

Audits by the VSP special investigations unit (SIU) are looking for suspected fraud or abuse. These are anything but routine and the auditors do not usually engage in an audit unless they have reason to believe they will find what they are looking for. These audits are unannounced. A VSP investigator comes to your office -- often on a day that the owner-doctor is not there -- and demands that you produce right then and there about 40 specified records. The auditor will copy those records or obtain PDF copies of electronic records. At the same time, the auditor will ask the office manager and other members of the staff "innocent" questions about the office in order to obtain information that the auditor can use to verify or confirm their findings. 

EXPERT TIP: Instruct your staff that if a VSP auditor comes in they should provide the auditor with the records requested, but they should NOT, under any circumstances, engage in conversation with the auditor or answer the auditor's questions. The auditors are trained experts at getting information they can use against you. Your staff should say only one thing: "I'm really sorry but you'll have to talk to the doctor about that." 

The outcome of these audits can be as simple as repaying a small amount of over-charge to VSP making referral to the district attorney for criminal charges and/or referrals to the Board of Optometry to initiate actions to revoke your license. These audits should always be taken seriously. 

While VSP can perform an audit for any number of reasons, currently, in late 2025, here are the main areas VSP has been auditing:

Contact Lens Fitting Fees

• VSP is looking to see if you are charging VSP patients that have the "Co-Pay" plan more than your "usual and customary" fee for any given kind of contact lens fitting. If they find you are charging more they will retroactively deny the claim and pay you $0 for the fitting. 

Contact Lens Fitting Documentation

• VSP is looking to see if you are documenting contact lens fits in compliance with their requirements. VSP requires acuities through the lenses, over-refraction, and slit lamp exam reflecting the lens fit, centration, and movement. Please see the Provider Reference Manual for details on what the minimum documentation requirements are. If you do not meet them VSP will retroactively deny the claim and pay you $0 for the fitting. 

Essential Eye Care Claims

• VSP is looking to see if (a) there are clinical findings that support the diagnosis; (b) the reason for the visit was medical and not routine vision; and (c) that you have the required documentation for all special tests done, including an interpretation and report. 

In-Office Finishing (IOF) Claims

• VSP is looking to see if you obtained your lens blanks from Plexus as required. (Note: if Plexus does not sell the lens you want to use you simply cannot use IOF for that order.)

Visually Necessary Contact Lens Claims

• VSP is looking to see if the record shows that the patient was eligible for VNCL benefits
  • Is there a diagnosis that supports a VNCL claim?
  • Are 2-lines of VA improvement documented for non-Keratoconus claims? 
  • Are your fees consistent with the complexity and not increased solely because the patient is VNCL eligible? 

While this is necessarily not a complete list of all reasons for a VSP audit, these are the most common audits at this time, and these audits often result in substantial demands for repayment from VSP. 

While not specifically documented in the VSP rules, VSP does typically allow providers to offer a -small- prompt/cash pay discount to patients that have no insurance coverage and are paying with cash. While I have seen VSP approve up to 30%, typically these discounts should be limited to 15-20% of your usual and customary fee (i.e., of the fee charged to VSP). 

EXPERT ADVICE: If you have a price list of some kind in your office there are some important guidelines to follow. First, DATE every price list so it is always clear what the most-current list is. Second, label the list as your "USUAL AND CUSTOMARY" fees and put the fees you would charge to VSP or any other insurance. Third, you can use ranges for some services. For instance, for a specialty CL fitting it can be "$600 - $1000" or whatever your range may be. You can note on the list that a prompt-pay discount of 20% is available for uninsured patients that pay in full at the time of the visit, but that is NOT your usual and customary fee and it is NOT the fee you should quote on the phone when a patient calls and asks for your fees. 

The answer depends in part on what kind of audit we are talking about. A quality control audit requests that you send in 10 records for review. These are routine audits not triggered by anything in particular, and most doctors will have one of these every so often. 

SIU audits, however, are audits performed because VSP already suspects you are violating VSP rules in some manner. There are several common triggers that make a practice suspectible to being audited. 

The primary ones are:

• A high volume of claims for Visually Necessary CL fitting
• A high volume of claims for Essential Eye Care relative to the number of "routine vision care" claims
• A high volume of "LAB100" claims indicating a non-VSP lab was used
  • This typically reflects an office not doing or not billing in-office finishing correctly
  • VSP will look to see if you have a Plexus account and if its usage corresponds with your claim submission
• Billing VSP for elective CL fitting at fees higher than customary in your market
  • Generally, if your CL fitting fees are $250 or higher there is a high risk of being audited
  • In most cases VSP will perform "secret shopper" calls to your office beforehand to get a cash-pay price quote
• Billing more for CL fits in patients with the VSP co-pay plan than other VSP plans
• A high volume of claims per credentialed doctor at your office

Each of these tend to be relatively easy audits for VSP that generate a large amount of financial recovery for them. By the time VSP actually does the audit they already have a good idea what they will find. 

First, be courteous to and cooperative with the auditor. The auditor ultimately has a lot of say over the audit and the penalties. It is helpful to have a cordial and respectful interaction with the auditor rather than a confrontational one. That said, here are some basic guidelines to follow:

• Do NOT chat with or volunteer information to the auditor. Every question the auditor asks is geared toward getting information from you and/or your staff that will help them defend the audit if you later challenge it. 
• Instruct your staff to obtain the records requested by the auditor, but do not answer questions. Tell the auditor that he or she will need to ask the doctor because he/she doesn't feel comfortable answering the auditor's questions. 
• Do not cut corners on supplying records; Provide everything asked for and more. For instance, if the auditor asks for the exam records from a given date of service, and the patient received contact lenses or a fitting, also provide the records from the contact lens dispensing and follow-up visits.
• Provide the results of any test you did such as OCT, topography, fields, photos, etc., whether or not it was billed to VSP. 
• Provide any records that reflect the dispensing of materials. This can be very important. 
• CHECK WHAT YOU ARE GIVING THE AUDITOR. Look at the PDF files being created and (a) make a copy for yourself and (b) be sure they are complete and that the EHR system printed everything. 
  • Many EHR systems do not print a complete record, especially if you have not CLOSED the record. Be sure to CLOSE the record before printing or creating PDFs of a record. Be sure all TABS are included in the PDF or are printed. 
  • Be sure all tabs concerning contact lens fitting are printed or included in the PDF

At the conclusion, ask the auditor if there are any additional records that the auditor needs to be able to do a thorough audit of the records. The auditor will likely ask you to sign a document concerning the audit. 

• Make a note that you asked if there was anything else the auditor needed and the auditor said there were no other records requested.
• If you could not find one or more records, ask if you can look for them and fax or email them to the auditor that afternoon or the next day. If the auditor says that is fine, add that to the document you are being asked to sign. 

Out of an abundance of caution, after the auditor leaves, send an email to the auditor reiterating that you asked if there was anything more that the auditor might need or want to do a thorough audit and the auditor said no, and that the auditor said you could send any records you could not find. 

Your contract with VSP, the Network Doctor Agreement (NDA) contains language that requires your cooperation with an audit. If you refuse to provide the auditor with records, unless you reach an agreement with the auditor to the contrary, the auditor will proceed forward and deem each and every claim that was going to be audited to be a "fail." You will be required to pay VSP as restitution 100% of the revenue from the prior 12 months that VSP paid you for the line of business being audited, and you will be terminated from VSP (which also means being reported to the National Practitioner Data Bank, NPDB). 

Now, in some cases, you may deem that a better outcome than if you provide the records. But it does represent a "worst-case-scenario" for the audit outcome. You will not be able to contest the audit since there were no disputed facts.

In some cases the auditor may agree to come back after the office closes, or even the next morning. But whatever agreement is reached with the auditor should be put down on paper and signed by the auditor so that there is no dispute later.  

In most cases of an audit by a Special Investigations Unit (SIU) auditor the auditor will have shown up unannounced and requested 40-45 records be provided. If that is what has happened to you, here are your next steps:

• Try and determine what was being audited. Was it all contact lens related? Essential Eye Care? Visually necessary contact lenses? Elective contact lens patients where the fee exceeded $250 (or some other amount)? 
• Obtain YOUR OWN copy of the records that VSP obtained from you. It is very helpful to know what VSP obtained from you, because they will not tell you afterward. 
• Do NOT -- DO NOT -- alter records. Do not add anything. Do not delete anything. EHR systems maintain logs of all changes and if records are changed you cannot succeed in contesting the audit, and can face problems far worse than just the audit. 
• If you have an idea what was audited, be sure VSP obtained from you ALL the records that pertain to that issue. For instance,
  • if it was a VNCL audit, be sure all records that support the diagnosis upon which the VNCL is based were provided.
  • If it was Keratoconus based on an exam last year, you should provide last year's exam. If you have a topography for the patient be sure VSP has a copy of that topography.
  • For contact lens related audits, be sure ALL contact lens follow-up visits tied to the audited date of service are provided. If it is Essential Eye Care, be sure all test results and interpretation and report documents were provide. If anything was not obtained at the time of the audit, provide it promptly to the auditor. 
  • For any audit involving materials, make sure the auditor has whatever proof you have of dispensing; something showing the date dispensed. 

Beyond this, there is little to do until you receive the audit results letter. 

First, don't panic. Almost ALL VSP audits result in a VSP "form letter" that accuses you of abusive and fraudulent billing. This is VSP trying to intimidate doctors in the hope the doctor will not contest the audit. It's the basically the same letter VSP has used for 20+ years, no matter what the audit findings were. Merely failing to sign some of your charts can result in this accusation of fraud. 

If you have not already done so, if the audit is patient-specific (that is, it is not a case where every claim was non-compliant for the same reason such as billing VSP more than you bill non-insured patients) you should look at the summary spreadsheet and print or save to a file all the records for each patient that failed the audit. 

Finally, because you probably don't have much time (less than two weeks) before a termination begins, you'll want to obtain the help of an expert quickly. You can email Dr. Steinberg at craig@csteinberglaw.org and send a copy of the 3-4 page audit result letter and the 1-2 page summary spreadsheet to him. He'll then reach back out to you to set up time to discuss the audit and the best strategy going forward. 

While it is always your option to contact the auditor, the short/best answer is usually NO.

The auditor's primary goal in talking with you is to obtain information he or she can later use against you later if you contest the audit results, and to try and convince you to not appeal the audit, just to pay it. In most (if not all) instances, whatever additional information you have is best supplied through your representative/lawyer rather than by speaking directly with the very person that has determined you failed the audit! 

Nearly every VSP audit results in a notice from VSP that the provider is being terminated from the panel. Only rarely, however, are providers ultimately terminated. Through the process of settlement discussion and/or appeals most providers are not terminated and are instead placed on "conditional status," which is VSP's form of probation. 

To be clear: most audits are about money. VSP wants money back from you. VSP terminates the provider so they can use the threat of termination as leverage to coerce doctors -- often successfully -- to waive their right to contest the audit and pay back money that the doctor should not have to pay back just to avoid being terminated. 

In most cases Dr. Steinberg can determine pretty quickly from the audit results what the true risk of termination really is and what the likely outcome of the audit will be. From there the best strategy for avoiding termination and reducing the restitution demand can be developed. 

Restitution is not a fine. Restitution is the recovery of money that was paid to you that you should not have been paid. 

Let's assume VSP was billed $100 for a service you normally charge $80 for, but because you (or your staff) accidentally billed the wrong amount, it should have been $80, VSP over paid you. In true restitution you would owe VSP back the difference between what they paid you and what they -should- have paid you had it been billed correctly. 

VSP, and VSP alone, views it differently. VSP uses a very broad definition of "restitution." They say that if you billed for more than you should have billed the entire claim should be denied. They say the "correct amount" is $0, not the amount you'd have been paid if billed correctly. So, in the world of VSP, "restitution" is usually 100% of what you were paid. This is, in my view, not a legally defensible position, but by using the threat of termination VSP is often able to force doctors to accept this legally untenable result. 

Thus, one can argue that the excess recovery by VSP is a "fine." And in many ways, it is, though it is labeled as recovery of an overpayment. Nonetheless, it results in a windfall for VSP. You provided the service. They were paid by their client for the service. But they keep the money and don't pay you. This is one of the primary drivers for VSP's aggressive auditing business. It results in enormous economic gains to them because they pay you nothing for the services and/or materials you provide, and they often succeed in doing so because of the threat of termination. 

VSP uses statistical extrapolation to determine the amount you must repay them. Here is how the process works:

• VSP identifies all records that meet the criteria they are auditing. Say it is VNCL claims. They will obtain a spreadsheet of all VNCL claims you submitted in the prior 12 months. This is the "universe of claims." There will be a total dollar amount you were paid for that universe of claims. For this example, let's say that adds up to $200,000. 
• From the universe of claims, VSP randomly selects 40 claims to audit. 
• Based on those 40 claims, VSP determines how much they believe you were overpaid. That is then converted into a percentage. 
  • Say you were paid $1000 for those 40 claims, and VSP says you were overpaid $600. That's an 60% overpayment. 
  • VSP calls that 60% the "dollars at risk." 
• VSP then multiplies the Dollars at Risk percent by the total from your universe of claims. In our example, that would be $200,000 * 60% = $120,000. 
• That $120,000 then is the amount they say you owe in restitution. 

The statistical method VSP uses assumes that whatever error occurred in the 40 randomly selected records will be found across the entire universe of claims. In practice, that's an approximation. The actual error rate may be more or less than that if all the claims were audited. But VSP is not required to audit all the claims unless they want to "claw back" more than one-year. 

This is how an audit of 40 records that found an overpayment of a couple thousand dollars leads to six-figure repayment demands. 

That's a common, but very broad question because every audit can be different and the process of opposing one may be very different than another. For instance, a "clinical" audit where the auditor found that your diagnosis was not supported by the clinical findings and so your Essential Eye Care claim was being denied is very different than an audit that found that your documentation of a contact lens fitting was insufficient. So every audit, and every claim within the audit, must be evaluated on its own. 

And that is exactly how an audit is challenged. By carefully evaluating the audit findings for each record and determining, do you agree or disagree with the auditor and, if you disagree, why do you disagree? Then we look at what proof or evidence there is to support your disagreement. 

Because of the statistical methods used by VSP, each of the 40 claims can have a significant impact on the money owed. Therefore, even if you can only defend 5 or 10 of the claims, that can mean reducing your restitution by tens of thousands of dollars. 

There are four steps in the process of contesting and/or resolving a VSP audit. 

SETTLEMENT

The first step is informal settlement discussions between your lawyer and VSP's lawyer. Many, if not most, audits are resolved via these informal discussions. 

ADMINISTRATIVE REVIEW

The doctor has the right to an administrative review of the audit findings. A written appeal is prepared stating in detail why you disagree with the audit findings, and providing all supporting evidence. VSP then responds in writing with their opposition to your appeal. These go to a "neutral" reviewer selected by VSP. Note: this reviewer is anything but neutral. It is a person closely affiliated with VSP that is paid by VSP to do these reviews. The only way that person keeps his/her "easy money" job is to side with VSP more often than not. So, do not expect a lot from this review. 

Any finding by the review that you are satisfied with and do not appeal further is a final result. VSP cannot appeal the decision of the reviewer, only the doctor can do that. 

PEER REVIEW HEARING

To the extent you are not satisfied by the administrative review you can appeal by requesting a peer review hearing. VSP will select three VSP providers, again, these are people closely affiliated with VSP, often Board or former Board members, to hear your appeal. VSP allocates about one hour. VSP's auditor will go first and present his/her reasons why the audit is correct. You will have about 20-30 minutes of that hour to make your case to the three members of the panel of why you disagree. Then lawyers for each side are allowed five minutes of closing argument. 

The panel issues a decision a couple weeks later. Either side can appeal their decision to the final stage, so the results of the peer review hearing are not final unless both you and VSP accept the results. 

ARBITRATION

If either side appeals a peer review findings that appeal goes to arbitration. Arbitration is like trial, but instead of a Superior Court Judge, the matter is decided by an arbitrator (often a retired judge). Because the arbitrator is NOT an optometrist this requires a far more thorough presentation of evidence. The arbitration process is similar to a court process, with each side being entitled to obtain "discovery" from the other. Arbitrator's have broad discretion to decide a dispute and do not have to strictly apply the law. The decision of the arbitrator is final, save for some narrow exceptions that rarely apply. 

If you are not a VSP contracted provider VSP cannot force an audit upon you. If an auditor shows up at your office asking to see or copy 40 records you do not have to cooperate or comply. You can ask the auditor to leave. 

Now, that may well result in VSP refusing to accept or process any claims you submit to VSP for out-of-network payment in the future. VSP has the right to do that. But if they want to audit your records they will have to obtain a subpoena or bring a lawsuit against you first. VSP's right to perform unannounced in-office audits is contractual and if you have no contract they have no right to perform one of these audits. 

As a general rule, VSP will not audit the same office a second time, provided VSP can determine that whatever triggered the initial audit is not repeating itself.

If, for instance your Essential Eye Care claims were audited and VSP found from the audit that you had improperly treated a lot of routine vision care visits as medical visits and billed for them under the Essential Eye Care program, VSP will look to see if your volume or frequency of Essential Eye Care claims has gone down and is now more in line with typical rates. 

Similarly, if VSP determined you were charging them more for contact lens professional services than you were charging generally (overbilling), VSP may call your office as a "secret shopper" and ask for your fee for a fitting, then compare that to what you are submitting in your claims for the same kind of fitting. If the fees are the same or nearly so, they will be comfortable that the overbilling issue is resolved. 

VSP generally does not re-audit an office out of any kind of retribution. They re-audit only if they determine that the doctor has not addressed or is continuing to engage in the same billing problem that triggered the initial audit. 

Interpretation and Report is a required component of many supplemental test procedures. That list includes, but isn't limited to, fundus photos, OCT (macula or optic nerve), angiogrpahy, ERG, VEP, visual fields, corneal topography, extended ophthalmosopy, anterior segment imaging, and dark adaptometry. 

NOTE: You can bill for only the technical component of a supplemental test using the TC modifier. In that case no interpretation and report is required. However, your reimbursement will be only for the technical component and will not include professional component reimbursement. 

To satisfy the Interpretation and Report you need to document the following:

• Clinical findings
• Interpretation of the findings,including comparative data reference (when available)
• Clinical management plan

Generally the report will say what test is being done and why, what was found, an "interpretation" or assessment, comparison to prior testing if there was prior testing, and your management. 

And, yes, this will be duplicative of what goes into your assessment and plan as part of your ordinary medical record. That does not matter, you need to have it anyway. And it should be labled as "I&R" or something of that nature so it is clear that THIS is your interpretation and report for that test. 

LIST OF TESTS REQUIRING INTERPRETATION AND REPORT

A complete list of codes/tests that require an interpretation and Report can be found in the Essential Eye Care Audits section byh clicking HERE or in the overall Guide to Audits and Billing by clicking HERE.