VSP Out-Of-Network Billing Cookbook


The following information is provided as a courtesy and is based upon information contained in a thread on the popular optometric social website, ODWire.

 

Not everyone is aware, but you can bill VSP as an "out-of-network" (OON) provider if you are not a contracted VSP provider. In fact, this is how Costco and others are able to represent that they "accept" VSP -- they bill OON. If you are not "in-network" (e.g. a VSP contracted provider), the trick is in knowing what the VSP benefits will be for any given patient, and in establishing policies for what you'll charge your patients. For purposes of this Cookbook, it is assumed that you're going to accept VSP's OON payments and co-pays as paying in full for the examination, and you'll apply VSP's material payments to your usual and customary fees, with the patient responsible for the balance. So, here is the step by step guide, courtesy of Dr. Jeanne Ruff:

 

When appropriate, bill their patient's medical insurance for exam fees and just file paper claim for materials to VSP as OON. Collect up front all co-pays and patient responsibilities on materials, just like you do as in-network, then mail in paper claim for exam and materials.

HANDLING VSP INQUIRIES & VERIFYING OON BENEFITS

Patient calls to schedule appointment – asks if you accept their insurance (which is VSP): Inform patient that you accept VSP's payment, plus the VSP co-payment, as payment in full for the examination, and for materials the patient is charged only the amount which is over and above VSP's coverage for whatever they purchase. A simple script goes like this: "we accept your VSP payment and copay in full for your examination, and we apply your VSP allowances towards the cost of any eyeglasses or contact lenses you purchase."

Call VSP IVR (interactive voice response), at 877-813-5112, to get the vision benefits for the patient:

o
IVR will ask for patient’s ID or last 4 digits of their SSN, and the date of birth of the member.

o If the system does not recognize this information, you will be transferred to an associate. Make sure you get the associate's name and the date and time of call. They will ask you some questions and if they find the patient under a specific ID #, they should tell you. o Tell the associate you would like all benefits: exam, frame/lenses, and contacts. They will give you the breakdown, which you should then document in the chart as follows (see form below):


o Exam: Copay $_____  Dr’s reimbursement $_______
o SV: $_______, pt pays the difference .
o BF/Progressive: $______, pt pays the difference .
o Trifocal: $______, pt pays difference.
o Lenticular: $______, pt pays difference .
o Contact Lenses: $______. They usually say this can be used against the fitting/evaluation as well as materials.
o Make sure you write down the authorization/reference number they give you.


To file the VSP claim use the ordinary CMS 1500 Form

 

o Fill in 1, 1a, 2, 3, 4 (can use same if same pt), 5 all, 6, 7 all (can use same if same pt), 8, 10a-c, 11a (if a guarantor – dob & sex), 11d no, 12 SOF & DATE, 12 SOF, 17, 17B, 20 no, 21, 23 (this is where you put the VSP authorization/reference number), 24 a, b, d, e, f, g, j, 25, 26, 27 yes, 28, 30, 31, 32, 32a, 33, 33a

o Fax the claim to VSP 916-858-4985; or mail to VSP Claims, PO BOX 997105, Sacramento, CA 95899 (this address has to go on top of claim as well)

 

VSP will only provide patient allowance and copay over the phone, so have your staff fill out this form (here is a PDF version of the form) and put it in the patient's chart:

VSP OON AUTHORIZATION FORM
P: 877-813-5112/F: 916-858-4985
VSP CLAIMS, PO BOX 997105, SACRAMENTO, CA 98599



PATIENT NAME:_________________________________________  DATE OF BIRTH:____________

GUARANTOR’S NAME:____________________________________ DATE OF BIRTH: ____________

PATIENT’S/GUARANTOR’S ID #/LAST 4 OF SSN: ________________
DATE OF SERVICE: _________________________________ (YOU HAVE 90 DAYS TO FILE THE CLAIM)

VSP BENEFITS:
 
EXAM _______________    REIMBURSEMENT _________
SV LENSES ___________     BIFOCAL LENSES ___________  PROGRESSIVE LENSES ______________
FRAME ______________   
CONTACT LENSES __________

VSP AUTHORIZATION/REFERENCE # _________________________
IVR OR REPRESENTATIVES NAME: ___________________________
DATE/TIME OF CALL TO VSP: _______________________________

DATE CLAIM FILED: _______________________________________
 
That's basically it. Each OON office should decide for itself if it wants to give VSP patients the ordinary VSP discounts on various materials (such as 20% off on "overage" amounts over and above the VSP allowance).
 
CAVEATS and ADDITIONAL INFORMATION:
1. If you are  asked by a patient if you are a VSP provider, the answer is no, you're not a VSP provider, but you will bill VSP and accept VSP payments toward the exam and any materials. So, you can say you "take VSP" but not that you are a "VSP provider."
2. Typical OON VSP payment for exam (co-pay + VSP payment) is about $60.00, but may vary. You can accept this as payment in full for the exam (and write-off the difference between that and your usual and customary exam fee), or you can charge your usual and customary exam fee, give the patient full credit for the VSP payment, and collect the difference from the patient. It's your choice. Most OON providers that "advertise" that they "accept" VSP will take the VSP payment + the patient Co-pay as payment in full for the professional services.
3. Be sure to document what you dispensed and the fees you charged, both to VSP and to the patient.
4. You do not have to use a VSP lab and are not subject to VSP's "contract" rules (e.g. what exam tests you must perform, vision vs. medical billing, restrictions on frame lines you can sell, etc.).
5. VSP OON payments for contact lens services are typically in the $105-$135 range (this is separate from the exam fee). Again, you can accept this as payment or, more typically, apply it to your usual and customary charges.
6. As an OON provider you will NOT be listed by VSP on their website as a VSP provider.