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Craig S. Steinberg, O.D., J.D.
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VSP Fill-In Doctor Rules

(Locum Tenens)

 

One of the most common questions that comes up with doctors is, do I need to have my fill-in and/or associate doctor(s) credentialed by VSP? The answer is critical because if VSP audits your practice and finds exams done by doctors that were required to be credentialed, but were not, VSP will deny all payments made for that patient -- both professional/exam services AND materials. That can lead to very large repayment demands. 

It is important start with some terminology. 

  • A "Fill-In" doctor is working on a temporary basis to replace a doctor that is out or going to be out for some reason. A fill-in doctor is not a regular doctor in the office. The work period has a known start and end date. Fill-in doctors may be planned, as in coverage for a known vacation, or emergency, as in coverage following an unexpected medical problem. 
  • An "Associate" doctor (aka an employee doctor) is a regularly employed non-owner doctor that is not filling in for anyone and that will be working for the office until such time that the associate doctor quits or is fired. 

Is Credentialing Required in Your Practice?

The next question is whether your form of practice even requires credentialing and, if so, to what extent? There are, broadly speaking, at least three "kinds" of VSP practices:

  • Private Practice - Traditional
  • Private Practice - Retail 
  • Commerical

NETWORK DOCTOR AGREEMENT

The first is the traditional private practice, owned and operated fully by optometrists, including the dispensary. These practices operate under a Network Provider Agreement (NDA) which is signed by the owner(s). Each associate doctor is credentialed via a small credentialing application that "registers" the doctor to a location. The "ND" is the network doctor, which is/are the practice owner(s). Associates do not sign a separate contract. The owner doctors that sign the NDA are the traditional "in-network" doctors. Even if a doctor is credentialed by VSP at another location you must still "register" or credential the doctor for your location. 

NETWORK PARTICIPATION AGREEMENT FOR QUALIFIED RETAIL LOCATION

A Network Participation Agreement for Qualified Retail Location is used by VSP for certain affiliated practices, such as those adjacent to a VisionWorks location and likely those affiliated with private equity practices (e.g., VSP Ventures, Total Vision, etc.). This agreement is very similar to the NDA except it does not require owning an optical and it creates two categories of doctors: owner-doctor and network-doctor. The "network-doctor" is a doctor working for the practice that is not an owner. The contract is clumsy, at best, as it appears VSP is trying to use its NDA in these retail locations, but the NDA was created for use only with owners of private practices. As a result, there are aspects of this agreement that are hard to interpret or understand, or just downright nonsensical. It appears that VSP expects every associate doctor to sign one of these agreements (hence the ND designation), but most of the contract makes no sense when applied to an employee doctor since that doctor does no billing, is not reimbursed, does not set policies or procedures, etc. 

  • To be clear, nothing about this Agreement makes sense. What that means for the non-owners is unclear. Can VSP audit them individually? Can VSP demand restitution or audit fees from them even though they don't own the practice or receive the VSP checks? Are they responsible for actions of other doctors in the office? None of this is clear because the contract appears to say yes, but none of that makes any sense in practice. 
  • These practices are also tightly integrated with the adjacent optical business which is owned and operated by VSP. That retail optical business, or its management company, oversees contracting and credentialing. 

ELECTION TO PARTICIPATE

The last is the commercial agreement used in locations such as a Costco. It is called the Election to Participate (ETP) agreement. It is a short agreement which allows the leaseholder doctor to bill VSP directly using 2020Source, but does not contain most of the requirements found in the other two agreements. It also incorporates a different provider manual than the "Provider Reference Manual" incorporated into the two other agreements. Doctor signing this agreement are not "in-network" though VSP, in the auditing context, claims they are when it is convenient to so. 

Why Does it Matter?

It matters because if VSP audits you and determines an exam was done by a doctor not credentialed by VSP -- for your office -- VSP will give $0 credit for either professional fees or optical generated by that patient. This results in a complete rejection of the claim and some of the largest restitution demands possible. What typically occurs is that, because the rendering doctor is not VSP credentialed, the billing will show the NPI of the owner as the "rendering" doctor. But this is not correct -- the owner was usually not the rendering doctor and the NPI is wrong. VSP claims that this was a "false representation" and on that basis will claim fraud and deny the claim once they discover who actually did the exam. 

Thus, before you choose NOT to credential a provider in your office you need to be CERTAIN that its not required. 

So, with that "clearly" understood, here are the rules as published by VSP in the Provider Reference Manual. 

Associate Doctors

The rules for associate doctors are easy: they must be VSP credentialed as an employee/associate doctor in YOUR office. The fact that they are VSP credentialed elsewhere does not satisfy VSP's requirements. If the doctor's name appears in the EyeFinity drop-down box he/she is VSP credentialed in your office. If his/her name does not appear and cannot be chosen as the rendering doctor, that doctor is NOT VSP credentialed and needs to be. Do that today. 

Until the Associate doctor is VSP credentialed he/she should not see VSP patients. That said, he/she can typically be treated as a 10-day or less fill-in doctor during the credentialing process, which typically takes a few weeks, and can see VSP patient on that basis. In this case the billing goes under the name of the owner-doctor. 

As soon as an associate doctor is VSP credentialed you must bill VSP under the name of the associate doctor.  

Fill-In Doctors (Non-Emergency Situations)

Fill-in rules are more complicated. This assumes it is not an emergency so the need for the fill-in doctor was known ahead of time (think vacation, planned surgery, maternity leave, etc.). These break down into three categories and the rules vary depending on whether the doctor has been credentialed by VSP at another location or has not been credentialed by VSP. The three categories are:

  • Will work 10 or fewer calendar days in the year (i.e., covering during a short vacation or short planned medical procedure)
  • Will work 11 - 60 calendar days in the year (i.e., such as covering during a maternity leave or a lengthy vacation)
  • Will work 61 or more calendar days in the year.

In the case of the latter, will work 61 days or more, that doctor must go through the normal VSP credentialing process as if he/she was an Associate doctor because the doctor is not a "fill-in" doctor if working 61 days or more in a single calendar year. That's deemed by VSP to be an associate/employee doctor. 

VSP Credentialed Fill-In Doctor

In the case of a fill-in doctor working 10 or fewer calendar days in the year, no notice to VSP or credentialing is required provided the doctor VSP credentialed somewhere (at another office location). You will bill VSP under the name of the owner. 

In the case of a fill-in doctor that will be working more than 10 days but not more than 60, VSP needs to be notified by phone that the doctor will be working as a fill-in doctor on a temporary basis and that he/she is VSP credentialed at another office. 

Non-VSP Credentialed Filli-in Doctor

If you are unable to find a VSP credentialed doctor to fill-in, the following rules apply:

  • If the fill-in doctor is to fill-in for a period of 10 days or less in a calendar year, VSP does not need to be notified and the use of a non-VSP credentialed provider is permitted.
  • If the fill-in doctor is to fill-in for a period of 11 days but not more than 60 days in a calendar year, VSP can either approve or deny the fill-in doctor. You must contact VSP at least 10 calendar days in advance of a planned absence with the fill-in doctor’s name, degree, license number and NPI number. VSP will verify the doctor's eligibility and notify you if the fill in doctor is approved to see VSP patients. 

Emergencies

Should an emergency situation arise requiring an immediate and unplanned absence of 11-60 days you must contact VSP as soon as the need for the immediate and unplanned absence arises, to provide the name, degree, license number and NPI number of the fill-in doctor and information related to the emergency situation. The fill-in doctor may be used for up to 10 days in total while the fill-in doctor’s verifications are obtained. If the emergency fill-in will be for 10 or fewer days no notice to VSP is required and you will bill VSP under the name of the owner. 

Generally, in no event shall a doctor or multiple doctors provide services on behalf of the same VSP network provider to VSP patients in the locum tenens capacity for more than 60 days in a calendar year.

VSP Penalties

VSP penalties for violating these rules are substantial. VSP will deem all revenue paid by VSP for a patient that was seen by a doctor who could not see the patient within these rules to be an improper payment and will seek 100% of the money back, including fees for glasses, frames, and CL materials. They will then extrapolate that back over a 1-year period. From a legal standpoint fees paid for materials should not be recouped by VSP, but to make that argument you will likely have to accept being terminated as a VSP provider. 

Commercial Practices

Private practice owners sign a Netword Doctor Agreement (an NDA). That NDA has specific credentialing requirements and it incorporates the VSP Provider Reference Manual which includes the provisions and rules above. Doctors working in a commercial practice setting are not "in-network" and do not sign an NDA. Most commonly they sign an "Election to Participate" agreement (an ETP). The ETP generally has no credentialling requirements. Though VSP still claims there is a credentialling requirement they have not yet, at least to Dr. Steinberg, been able to identify one. It remains an open and disputed issue whether these rules apply in the Election to Participate/commercial setting.