Audit Issues: VSP Contact Lens Fitting 

VSP CL Professional Services

VSP has begun "cracking down" on doctors that do not fully and/or properly document contact lens professional services, i.e., contact lens fittings. If you are audited, and you billed VSP for contact lens professional services (not materials), the VSP auditor will be looking for specific documented items to validate your right to payment for those services. If those test results are not found in your records VSP will consider you to have been overpaid for contact lens fitting services, and you may be facing a large restitution order. Don't make it hard for the VSP auditor to find -- have a clearly identified contact lens services area in your charts and/or complete your Electronic Record for CL fits!

EXPERT TIP: If you have not fully documented your CL fitting in accord with VSP's minimum requirements you have not done a CL fitting as far as VSP is concerned, and you are not entitled to be paid for -- and will not be paid for -- your professional services. DOCUMENT DOCUMENT DOCUMENT.

There is much confusion in VSP's CL service rules, and as a result, many doctors do not have adequate (e.g., VSP compliant) documentation to support having provided professional services to their contact lens patients. It is commonplace, especially with a patient that is doing well with their contact lenses, for doctors to evaluate the patient's current lenses and issue an updated prescription (along with selling a new annual supply of materials), but to have minimal documentation related to those contact lens-related professional services. Following these guidelines, and using the model CL exam forms below, should help you address these issues and protect you against a strikingly adverse VSP audit outcome.

VSP recognizes three kinds of professional CL services:

• New Fit
• Refit
• Routine Progress evaluation

A new fit is for a patient that has not worn contact lenses before.

A refit is for patients that have been wearing contact lenses, but you are making a change to the lens type or lens parameters. VSP does not consider issuing a new prescription (i.e., increasing the sphere half-a-diopter!) to constitute a "refit", and they require that certain data be recorded to justify payment for a "refit."

Routine progress evaluations are for the annual contact lens check of a patient that has been wearing lenses when you are not changing or do not change the lens parameters, only checking the patient and updating the prescription and/or dispensing a new annual supply of lenses. In each type of service there are specific things which VSP expects to be recorded, such as CL History (including wearing time, cleaning, replacement schedule), certain findings (SLE, Over-refraction, Keratometry, VA's w/ lenses), Assessment, and Plan for the new prescription. 

Usual and Customary Fees

VSP pays according to your usual and customary charges for Fits, Refits, and Routine Progress Evaluations, subject to the limits of the patient's coverage (note: for visually necessary, the plan limits do not apply and you will be paid according to your U&C, which can be well over $1,000 for fitting certain lenses). Your fees for each contact lens service (fit, refit, evaluation) may be the same, or may vary (e.g. new fits costing more than refits, etc.). It is important -- essential -- that you have an established and up-to-date Fee Schedule that reflects your U&C charges for these services. It may be conveniently broken down by lens type (e.g. soft spherical, soft toric, soft multifocal, GP, Hybrid, Scleral) and may include several levels for each of those categories (e.g. Routine, Complex, Custom).

EXPERT TIP: Use a Contact Lens fee schedule, and update it regularly. At least every six months. Date the schedule so the last update is noted on it. Throw away old fee schedules! Be sure your fee schedule includes all your professional service fees. It may be convenient to use a "unit charge" and then set each service as a certain number of units. That way you can change your fees easily by adjusting the unit charge, or the units for any given service. A model form is available below. 

For a Microsoft Word File of a Model Fee Schedule that you can modify for your needs, click [HERE]. 

PROMPT PAY DISCOUNTS - VSP does typically allow a "reasonable" prompt-pay discount for patients with no insurance. That discount should generally not exceed 20% off your customary fees and it should not be considered or quoted as your usual and customary fee. 

To make it easier to meet the VSP requirements I have developed for myself CL forms and a model fee schedule. In every case that VSP is being billed for contact lenses, either materials, professional services, or both, one of these forms will be completed. Dispensing and a follow-up visit will be documented at the bottom of the form (in ALL cases, VSP wants documentation showing date dispensed). These forms are offered for you to use at your discretion. I cannot guaranty that they satisfy all VSP requirements, but they are what I use after having participated in dozens of VSP audits arising out of CL billing issues.

Model VSP Contact Lens Exam Record 

Documentation is the key to your audit outcome. Without good documentation you will not have good defenses to a bad outcome and a bad outcome is all but certain. For that reason, Dr. Steinberg has developed a model CL exam record designed for use on VSP patients for CL fits, refits, and progress checks. Progress checks refer to annual (yearly) CL evaluations in which you do not change the lens parameters. If you one of these forms for each patient that you bill VSP for ANY contact lens related materials or services, complete the parts of the form that are applicable, and then save or scan this document into the patient's record, you will almost certainly meet all VSP's CL fitting documentation requirements. 

For a PDF of the model CL fitting page that you can use to ensure you meet documentation requirements, click [HERE].