2025 VSP Audit Targets

As of the end of 2025 the following areas appear to be the primary targets on VSP's "radar" for auditing. This does not mean VSP cannot or will not audit other areas of concern to them, but based on the audits being most commonly seen by Dr. Steinberg, these are the areas you need to be particularly mindful of and be sure you are 100% compliant. 

EXPERT TIP: Always remember the "golden rule" of billing: if you don't write it you didn't do it. That includes such mundane things as dispensing. Be sure to document that date you dispense materials and what was dispensed or VSP will conclude that you billed for materials you did not provide! That also goes for contact lens fitting -- if you want to defend an audit your records must show that you actually did a CL fitting -- and comprehensive examinations (if tonometry is missing you cannot bill for a comprehensive exam). 

Essential Eye Care

The issue here is billing for supplemental tests, fundus photos (92250) in particular, but not exclusively. VSP is auditing and looking for two things: evidence of medical necessity and that you have a proper interpretation and report (I&R). Note that the I&R should spell out the medical necessity for the test by stating not only what was (or was not) found, but in what way that is influencing your management of the patient. Medical necessity means the test was helpful in either diagnosis (think B-scan to diagnose a retinal detachment or OCT to diagnose macular edema) or in the management of the condition (think choroidal nevus to monitor change or cup/disk ratio in a glaucoma suspect). See the VSP FAQ for information on what requires an interpretation and report and what one is. 

Secondarily, VSP is looking for "upcoding." Upcoding means you are billing for level 4 and level 5 (99204/99214 or 99205/99215) at an unusually high frequency indicating that you are likely up-coding to a higher level than warranted. Optometry RARELY has a level 5 claim because there are not a lot of test results to assess, and only occasionally a level 4 exam is warranted. If more than about 20% of your claims are billed at level 4 or 5 there is a very high risk you will be audited and found to have billed a higher level than warranted, resulting in a recoupment of the overpayment by VSP.

Finally, VSP is looking to be sure you are not billing "routine" exams under the Essential Eye Care plan. Your chief complaint/reason for the visit MUST reflect a medical complaint and not that the visit is "annual" or "routine," and your assessment and plan must address the medical findings and follow-up. If you are submitting a high volume of claims under the Essential Eye Care plan you can expect to face a VSP audit. 

CAUTION: VSP is likely to survey or call patients ahead of the audit to ask if the visit was routine or if the patient had a specific problem or complaint. It is important to document carefully, and if the patient wrote "routine" or denied any problems in your paperwork you can expect VSP to question any medical claim billing. 

Contact Lens Fitting Fees

The issues here start with your fitting (92310) fees. VSP is looking for two things: fees billed to VSP that are higher than the fees billed to patients without insurance and high fees generally. If your CL fitting fees are above "ordinary" for your situation (i.e., a Costco or Walmart practice charging $450 to fit spherical daily lenses) there is a very high risk of being audited and found to be "overbilling" VSP. 

EXPERT TIP: VSP will allow a "reasonable" prompt-pay/cash-pay discount. This is generally on the order of a 15-20% discount. But this is NOT your "usual and customary" fee, it is a discount applied to your usual and customary fee. When billing patients you should bill the full/non-discounted fee, then apply the discount in a separate line item. Your fee scheduled should NOT reflect your discounted fees, it should show your full usual and customary fees. 

Secondarily, when doing a fee audit, VSP will examine the documentation to see if you have properly documented the fitting. That means acuities through the lenses, notes reflecting centration and movement, and over-refraction (subjective or objective). If your chart does not reflect these elements your claim will be denied as not supporting that a CL fitting was performed. 

Credentialing

In a private/professional practice, every doctor that sees VSP patients must be credentialed. If the doctor does not appear on the VSP drop-down box when billing it means the doctor is not VSP credentialed. VSP will deny all claims arising from a non-credentialed doctor. 

In commercial practices that are subject to an Election to Participate (and not a Network Doctor Agreement) the rules are murky. The Election agreement has no credentialing requirement. VSP, however, believes it is required even though it is not anywhere in their agreements. It is best to be sure every doctor that sees VSP patients -- even if just one day a month -- is credentialed as an employee doctor. 

In-Office Finishing/Improper Use of Non-VSP Lab

This is an easy one for VSP and reflects two common situations: not complying with the IOF rules and using a non-VSP lab.

For proper in-office-finishing (IOF) You must obtain your lens blanks for IOF from Plexus. If Plexus does not sell the lens you want to use you cannot bill it under the VSP in-office finishing program. VSP auditors don't even need to leave their chair to determine if you have a Plexus account and are ordering from it at a level that corresponds with your volume of IOF claims. 

As for using a non-VSP lab (what VSP calls "Lab 100"), you are only allowed to do so if you have documented in the patient's chart a valid emergency. Examples would be the contact lens patient that cannot wear lenses due to infection and does not have current glasses or the glasses patient that lost/broke glasses and does not have a backup pair. You must document this in the chart. "Emergency" does not include needs their glasses quickly due to a vacation or because the VSP lab does a lousy job or takes too long! 

If you are either billing VSP for IOF but not buying from Plexus, or you are billing VSP for a non-VSP lab (called Lab-100), you will likely be audited and all claims for materials (including frames) will be denied for not complying with their rules and/or not using a VSP lab.

Visually Necessary Contact Lens (VNCL) Claims 

In 2025 this source  of audit has become less common, but it is nonetheless a VSP favorite, especially since implementing the 2-line rule in 2024 because many doctors are not aware of the new rule. Thus, an otherwise "obvious" VNCL claim such as in keratoconus may be denied because the 2-lines of improvement over glasses was not demonstrated.

VSP will audit VNCL records if you submit a high volume of VNCL claims relative to others. Their audit will focus on three things:

• Do your clinical findings, assessement, and plan support the diagnosis the VNCL benefit is based upon?
• If the 2-line rule applies (as it often does), have you documented the two-lines of improvement?*
• Are your fitting fees increased solely due to the patient being eligible for VNCL benefits (as opposed to increased complexity of the fit)?

WARNING: You cannot charge more for a CL fit solely because the patient is eligible for VNCL benefits. Fitting fees must be based on the complexity of the fit and your usual and customary fees -- without consideration of the payer or the patient's benefits. VSP will deny claims where you charge more for someone that is, say, -3.00 OD and -6.00 OS than you would if they were -3.50 and -6.00. 

* The "2-Line rule" added in 2024 requires that, except for certain specified conditions, you must document that the patient sees at least two lines better through the contact lenses than they do with their best corrected visual acuity (BCVA). This effectively removes many otherwise-eligible conditions, such as corneal neovascularization, corneal dystrophies, and even early or mild keratoconus, from qualifying for VNCL benefits. Exceptions to the 2-line rule include nystagmus, anisometropia (3D or more), high ametropia (10D or more), albinism, pupillary abnormalities, and aphakia. (The VSP manual lists several others that are less commonly diagnosed.)