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Craig S. Steinberg, O.D., J.D.
a Professional Corporation

craig@csteinberglaw.org

 

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VSP Contact Lens

Professional Fees

 

VSP's rule on contact lens fees is simple enough:

THE RULE: You must bill VSP your "usual and customary fee" for a contact lens fitting or progress check.

Simple on the surface, but not necessarily simple in practice because VSP does not define "usual and customary." Here is what VSP tells you about what usual and customary fees means according to VSP:  "Usual and Customary Fees. These are a doctor's standard, unmodified charges for given services." This vague explanation creates far more questions than it answers. For instance: 

  • Is this the lowest fee you will accept?
  • What does "unmodified" mean? 
  • Is this your fee for cash-pay uninsured patients?
  • Is this the fee you bill out most commonly?
  • Does "customary" mean the going rate in the local community?
  • If so, what affect does that have on the fee you charge? 

VSP's Provider Reference Manual (the PRM can be located in the VSP Manuals section of EyeFinity), offers little or no help. The result is that doctors are "set up" for failure when they are audited. For example, let's assume that 10% of your patients are cash-pay and 90% are a vision plan members such as VSP or EyeMed. Say you charge those cash-pay patients $100 and you charge everyone else $150 for the same service. Which one is your usual and customary fee, and why? Is the $100 fee your usual and customary fee because that's what you charge a cash-pay patient? Or is that a "modified fee" because it is a cash-pay patient and $150 is your usual and customary "unmodified" fee? 

There is no clear definitive answer and nothing in the VSP manuals will tell you. But here are some guidelines that 20 years of auditing defense experience have shown:

  • Though it is not in their rules, VSP expects your CL professional/fitting fees to correspond to the general complexity of the fit.
    • VSP is, at a minimum, uncomfortable with having a single standard CL professional fee that applies to all elective fits.
    • VSP expects the fee for a spherical daily lens to be less than a toric, or monovision.
    • VSP does not consider filling a -10.00 to be more complex than a -8.00, as an example, but fitting a patient with a history of GPC, dry eyes, or post-LASIK may be more complex and a higher fee may be justified (so long as you can defend it and it is your usual and customary fee for that type of patient).
  • VSP allows a small cash-pay/prompt pay discount of about 15-20%, but discounts of 40%, or 75% will be seen as abusive billing. However, nowhere is any of this written in any VSP rules. If Usual and Customary is your "standard unmodified" fee, and the modification is a 50% prompt pay discount, would this violate the rules? Again, there's no guidance on this. 
    • Be sure your chart/fees reflect that a DISCOUNT was applied and that the fee charged is a "modified" fee. Post the usual and customary or standard fee, then the discount (perhaps with a description as, "modified," so the record is clear if you are audited. 
  • VSP considers CL professional fees that are far above the customary rate in the community to be "abusive billing" even if it is what you charge everyone.  
    • Some doctors, especially ones with a high volume of VSP patients with the co-pay plan, have tried implementing a policy of charging every CL fit at a high rate (say $700), recognizing that cash-pay patients will reject that fee and go elsewhere, but the patients with the VSP co-pay plan will more than make up for the loss of cash-pay patients.

Idealistically speaking, if you are audited and the example above is similar to your office, and you are determined in the audit to be "over billing" VSP and ordered to repay them, you should be able to appeal and oppose the audit and prevail in your argument. However, VSP will use the threat of terminating you and keeping you terminated during the pendency of the appeal -- even though that generally violates VSP's own rules -- to coerce you into repaying them even though you didn't over charge them in order to avoid a termination. That's VSP's MO and that's why they terminate almost everyone initially. 

In order to assist doctors with a fee schedule that aligns with VSP expectations, and also a documentation chart that assures compliance with VSP's minimum requirements, Dr. Steinberg has developed some sample forms that can be used (with appropriate modifications) by any provider that wants to have the best chance of avoiding audit findings of CL overbilling and insuffcient documentation. These are available at no charge by downloading them from the links below:

NOTE: the fees in the CL Professional Fee Rubicon are examples only. You -must- adjust those fees to your usual and customary fees. You do NOT have to charge less for a progress check than a new fit or refit, you can charge the same fee for each (though a new fit is commonly more because of insertion/removal training time and higher risk of failure).