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VSP Out-Of-Network Billing

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 many commercial and "big box" businesses 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.


However, effective July 1, 2018, VSP has built a wall to try and make it as difficult as possible for an OON provider to serve their patients. VSP will no longer provide an out-of-network PROVIDER (OD, Ophthalmologist, or Optician) with information about the patient's OON benefits. They will not tell you if the patient is eligible, nor will they tell you what the OON benefits are for the patient. VSP now requires that the patient or VSP member speak directly with VSP member services to obtain any information about their OON benefits or coverage. Moreover, reports are that VSP uses this opportunity to suggest that the patient will obtain better benefits if they go in-network, effectively trying to convince the patient to NOT do business with you or any other OON provider.


VSP will still accept claims from OON providers, and will pay OON providers directly if the claim form indicates the provider is accepting assignment of benefits. They just will not tell OON providers what the benefits or payment will be, thus hinduring your ability to provide information or good service to your patients.


Possible Solutions


Providers are trying a few different methods of dealing with this "new reality" from VSP. In most cases, OON providers do not want to burden their patients with having to call VSP, nor do they want to allow VSP the opportunity to tell patients they should go elsewhere to use their VSP benefits. Here are a few suggestions on how providers may continue to provide their patients with the best possible OON care and benefits.


1. Start building your own database of the VSP OON benefits for various employers in your community. Begin by reviewing the OON benefits paid over the past year, identifying the employer or plan ID, and the amounts paid for exam, frames, single vision, bifocal, and progressive lenses, add-ons (scratch coat, anti-reflective coat, high-index, etc.) and for contact lenses. The fact is, those benefits change little, if at all, from year to year. OON Providers in an area can meet and share their data so that the OON benefits are simply already known.


2. Estimate the VSP OON benefits for the patient, and, for patients that pay using a credit card, obtain patient credit card information and authorization to charge them for any shortfall when the VSP payment comes in. Use a form that advises the patient you will use the credit card information to refund to them any over-charge, or charge them any under-charge.


3. Estimate the VSP OON benefits for the patient, but, if they don't want to use suggestion 2 above, let them know that if they want you to accept payment from VSP, you'll need to get that payment before their glasses can be dispensed so that the correct charge can be determined. In most cases VSP pays within 2-3 weeks.


4. If you want to the patient to call, have them do so in your office, and develop and use a SCRIPT for the patient to use so that the process is as streamlined as possible. It may also be advisable to warn the patient that VSP may try and convince them to go elsewhere, and have a script ready for the patient to use to cut that off (i.e., "Thank you, but I do not want to go somewhere else, so I'd appreciate it if you'd just tell me my 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. So, we try and ensure you receive the most value VSP offers when you obtain services or materials in our office."

When the patient arrives, use one of the methods above, or, if you choose option 4, help the patient call VSP. Have the patient tell VSP he/she would like all benefits: exam, frames, lenses, and contacts, and have a form where the patient can write the amounts down as they are provided. 

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:


Vision Service Plan
Attention: Claims Services
P.O. Box 385018
Birmingham, AL 35238-5018

(this address has to go on top of claim as well)


VSP provides some OON billing information at this website: https://www.vsp.com/faqs/s/article/Submitting-an-Out-of-Network-Claim

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:


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)

EXAM _______________    REIMBURSEMENT _________
SV LENSES ___________     BIFOCAL LENSES ___________  PROGRESSIVE LENSES ______________
FRAME ______________   

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).
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. Frames generally are reimbursed about $70.
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.