VSP Approval
Will You Be...VSP Approved?
What you need to know to prepare for and pass an audit.
BY TERRI B. GOSHKO, Senior Associate Editor

Chances are you're as eager to undergo a Vision Service Plan (VSP) audit as you are to undergo one by the IRS. But while you may not be able to prevent an audit, you can prepare yourself so that it's likely that you'll pass with flying colors. I'll explain how.

Why they come to you

Who gets chosen for an audit? Last year, VSP set a goal: Over the next 5 years, it will audit all of its 19,000 doctors who file more than 100 claims each year. VSP conducts about 4,000 audits annually.

VSP wants to ensure two things when it audits your practice:

• that you're complying with standards of care and documentation
• that you're delivering quality care to each of your patients.

What they're looking for

According to Dennis Humphreys, O.D., VSP's optometry director, and Lori Doucette, senior media relations specialist for VSP, an audit studies these aspects of your practice:

Office standards. Is your office clean and well maintained? Do you observe infection control standards? Are your equipment and instrumentation up to date? Do you comply with the Americans with Disabilities Act in terms of handicapped patient parking and building access?

The eye exam. Do you perform all the procedures required for the level of exam for which you're billing?

Medical record documentation. Do you supply biographical data for patients? Do you sign and date your records? Are such important things as medications taken and allergies listed?

Finances and billing. Are you following VSP billing practices for deductibles, options, charges or overcharges?

They're here

VSP conducts audits on site in your office or by mail-in review.

For an on-site review, the auditor arrives on a date that's usually scheduled ahead of time with a list of patients whose records he will examine. He studies the records and then does a walk-through of your office.

After that, he'll sit down and discuss his findings with you. Because he'll often want to review some of your records back at his own office, he generally won't tell you immediately whether you passed, but he'll mail his judgment later.

For a mail-in review, your staff pulls the required records. You complete various forms, photocopy the entire medical and financial record and mail them in. But don't think you'll get off easier this way; Dr. Humphreys notes that auditors have been overwhelmingly honest in mail-in reviews, which are held to the same standards as on-site reviews.

The following four possible levels exist for a VSP review:

1) Educational review. This practice review identifies areas in which you need improvement and makes it more likely you'll pass your first real review. No penalties are assessed for any shortcomings, but you must refund any patient overcharges to the patient (this rule applies in all levels of the review). If you pass with a score of 80% or higher, you're considered "in good standing" and won't be audited again for 5 years.

2) First formal review. If you didn't pass your educational review, now's the time to shape up. If you score below 80% now, VSP will give you an Improvement Action Plan (IAP) outlining what you must do to address their concerns. VSP will assess financial penalties and will require you to pay a $500 re-review fee on your next review, within 12 months.

3) Second formal review. Financial penalties for records with discrepancies will be assessed and calculated on your claim volume for 12 months. A score below 80% means a $500 re- review fee for your third review.

4) Third formal review. If you score below 80% this time, you'll be referred to the Co-Medical Director, Optometry, for review and correction action. You might be removed from the VSP network and will be assessed financial penalties.

If you fail your audit and receive an IAP, you need to sign, date and return it within 30 days. In VSP's view, you have voluntarily resigned from the network if you don't return the IAP within 30 days.

The most common errors

The most common errors that turn up during reviews include the following:

• Eye exam procedures, such as visual acuities and ophthalmoscopy, weren't documented. "Remember," cautions Dr. Humphreys, "if it's not documented, VSP assumes you didn't do it."
• Medical records weren't signed or dated.
• Patient medications and allergies to medications weren't listed.
• Questions about use of tobacco, alcohol or unprescribed drugs weren't asked.

So what can you do?

VSP supplies various resources to help you learn in detail what you need to do to pass a review. "Tools for a Successful Provider Review" is available for download at Eyefinity.com, or you can call VSP's Provider Services Support Line at (800) 615-1883. Use this brochure as a self-assessment tool by which you alert yourself to any shortcomings ahead of time. VSP also sponsors seminars.

In fact, if you familiarize yourself with the guidelines and follow them, passing an audit should be easy, according to Lena Chu, O.D., owner of Chu Eye Associates/Eyeworks in Fort Worth, Texas. Dr. Chu passed an audit in March. "I didn't have to do any special preparation," she notes. "I just followed their guidelines, which are like those that any good practice would follow."

Forewarned is forearmed

VSP believes the educational aspect of reviewing is the most important. "Optometry has grown and changed so much in the last 10 to 20 years," Dr. Humphreys observes, "and doctors need to understand that the importance of proper documentation and adherence to standards has grown too." The review and preparation for it can teach you what you need to know in today's more complicated practice arena.

So arm yourself with your research tools, assess yourself and fix whatever you think is wrong. If you're well prepared, you can find yourself in good standing with VSP -- and off the hook for 5 years.