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

craig@csteinberglaw.org

 

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Record Keeping Requirements

 

Often overlooked, because it is buried deep into the VSP Provider Reference Manual (PRM) in its section on auditing, VSP states that providers are required to maintain "itemized financial records" and provide those at the time of an audit. The PRM goes on to say that failure to maintain or provide these records can result in the denial of payment (even if it is verified that you provided all the services and materials and are otherwise 100% in compliance with VSP rules)! 

Note: Please always remember that VSP is looking for -- any reason -- to deny payment for seemingly valid claims and to do so they create rules, often unrelated to care, and hides those rules deep into its manuals. This creates the ability to do just that: deny payment for valid claims based on failure to comply with a rule you had no idea existed and has nothing to do with patient care. 

WARNING: VSP's "Well Vision Savings Statement" does NOT satisfy the requirements for "itemized financial records."

 

So with that in mind, it is essential that providers know these rules and expectations. For specifics you should review the "Services Subject to Audit" section of the online provider reference manual accessible through EyeFinity and VSP Online. But briefly, here are the rules you need to be aware of.

Generally speaking, your records should include the appropriate CPT codes and descriptions, quantities provided, and the amounts billed to and paid by the patient and insurers (don't forget to include payments from coordination of benefits). So, even if the patient paid nothing, you must still have records of the transaction showing what was billed to insurance. The records must include all professional services (exams, testing, etc.) and all services related to materials (CL fitting), as well as the materials themselves. For contact lenses and eyeglasses, the requirements are: 

CONTACT LENSES

For all CL types (elective, VNCL, etc.) you must record the following: 

  • Patient name and date of service
  • CL brand, Type, Quantity, and -- IMPORTANT -- the date the lenses were dispensed
  • U&C cost for the fitting and the materials 
  • The amount billed to insurance and the amount paid by the patient (and method of payment)
  • Invoices for materials ordered or an indication of dispensing from stock

VSP now also requires that you keep a list of your U&C fees for services and materials and to provide a copy to any VSP Representative upon request. For additional information please see the Contact Lens Fees/Documentation section in Free Forms where at the bottom you will find a model fee schedule that satisfies the requirement for a list of your Usual and Customary fitting fees. Your material fees can be added to this model. 

GLASSES

  • Patient name, date of service
  • Lens type and lens options
  • Frame make, model and retail cost, as well as the invoice showing acquisition cost
  • The date the glasses were dispensed
  • The amount billed to insurance and the amount paid by the patient (and method of payment)
  • Lab invoice(s)

If you are audited do not wait for the auditor to request this information, just provide it. A couple of caveats:

  • Invoices do not have to be kept with the patient record, they can be in a separate file but need to be accessible.
  • This data, if not otherwise in the patient record, can be recorded as a No-Charge line item in the patient's account. This is especially helpful for dispensing dates. 
  • Dispensing dates are essential. VSP assumes the materials were NOT dispensed if there is no dispensing date recorded and will deny payment on those grounds. So be sure to record --somewhere-- in the patient's record the actual date of dispensing (or, if shipped, the date shipped)