VSP Targeted Audits

VSP performs two kinds of audits: quality control (QC) audits, and targeted audits.

Quality Control Audits

Every practice should expect a QC audit every few years. These are routine audits in which you are asked to send VSP about 10 patient records and some time later you receive back a report assessing your compliance with VSP rules. Unless this routine audit identifies a clear pattern of fraud, these audits rarely lead to anything more serious than corrective action. 

Targeted Audits

A "targeted audit" is performed by a special division of VSP called their SIU, or Special Investigations Unit. The SIU is made up of a small group of trained fraud investigators employed by VSP. They regularly examine data to watch for billing patterns which suggest to them that you may be billing improperly or even committing fraud.

Targeted audits occur only when VSP already has reason to believe there are significant violations of the VSP rules or regulations occurring and after VSP has engaged in preliminary investigation to confirm its suspicions. So if there is an auditor there in your office you can be CERTAIN that VSP already believes you are in violation of their rules and their reason for being in your office is to get the proof they need to seek substantial monetary restitution from you. 

EXPERT TIP: VSP does not do a targeted audit to find out if you are violating their rules; they do a targeted audit confirm their suspicion and PROVE you are violating their rules. You should govern yourself accordingly. Don't cooperate, rebut. Prove you are NOT violating their rules by providing them everything, even information they may not be asking for. This is not a time to play "hide the ball" unless you have something to hide! 

For instance, billing a high volume of visually necessary contact lenses, having a high dispensing rate compared with other offices in your area, billing for a high volume of punctal plugs, and billing a high number of low-power prescriptions (+/- 0.50D) have all been recently known to trigger a "targeted audit." Anything you bill VSP for more than others in your area puts you on their "radar" and may trigger one of these audits.

In a targeted audit a VSP fraud investigator from the SIU will come into your office unannounced, and ask for anywhere from 30-50 charts (usually 40-44), and will wait for you provide them immediately. These audits proceed even if you are not present. The charts are copied or printed and the auditor returns to his/her office and determines if you appear to be violating VSP rules. Targeted audits often lead to demands by VSP that you repay VSP $100,000 or more in "restitution," and/or removal from the VSP panel. Then, to add salt to the wound, VSP will begin withholding all VSP payments to you to pay down the restitution, even before you have a chance to appeal the audit findings.

If you are in-network (contracted) with VSP you cannot refuse to cooperate with a targeted audit, nor should you. It is much easier to defend a poor audit outcome than it is to defend refusing to be audited. The latter almost always results in termination from the VSP panel as VSP considers every chart they -would- have audited to be a "fail." 

If you are out-of-network (non-contracted) VSP has no authority to audit you or require that you allow or cooperate with an unannounced audit. You can (and probably should) courteously but firmly ask the VSP auditor to leave. If he/she does not have a subpoena for records they should not be provided. If VSP wants the records they can initiate a legal action and obtain them via ordinary discovery once the rules requiring notification of the patients is completed.