VSP Contact Lens Fitting and Dispensing: Audit Traps


When I graduated from optometry school many years ago, fitting soft lenses involved multiple visits, and fees were "global" and included both the lenses and the professional services, including fitting and follow-up. Few doctors had lens inventories, we would order lenses and our invoices showed the lenses we ordered and the name of the patient we cl-on-fingerordered them for. "Extended wear" patients were checked first thing the next morning, and nearly every CL dispense had a follow-up visit, if not several. New patients had a "break in" period to build up wearing time from a few hours to a full day. As a result, our contact lens charts were typically full of contact lens follow-up data. Wearing schedule, fit, movement, acuities, overrefraction, and even the appearance of the mires from a keratometer were typically recorded for each of several visits.
 

Today we often see a new fit perhaps a week later, and many (most) of our patients already wearing lenses, doing well, and need only an updated prescription and a few more boxes. We dispense from our inventory, or drop ship them directly from our supplier, perhaps check the lenses right then, if at all, and the patient is happily on his or her way. VSP is billed for an exam, and the contact lens professional (fitting) fee. What could possibly go wrong?


Then you get audited by VSP, and, to your dismay, even astonishment, they say that you are overbilling for contact lenses, you don't have invoices to show lenses were ordered, you haven't been documenting fitting and/or follow-up visits, and there is no evidence lenses were actually ordered or dispensed. VSP is retroactively denying payment for your CL fitting fees, and denying or reducing payment for your materials. You owe VSP more than $100,000 in restitution, because they are applying it to your last three years of CL services, and they are terminating your provider agreement. Recently I've noticed the problem is even more apparent in offices using electronic health records, where its all too easy to skip documenting "routine" information.


Will I Be Audited?


Audits are triggered by a number of things, any one of which puts you "on the radar." If you are dispensing contact lenses at a rate notably higher than the VSP average (e.g. if 50% or more of your patients are getting contact lenses) you are likely to be audited. If you are billing for visually (medically) necessary contact lenses more frequently than is typical an audit is likely. And if you are just doing a higher volume generally than others in your area you are likely to be audited.

 

VSP audits begin internally at VSP. If you show up on the VSP radar (VSP investigators receive regular reports showing what practices are doing what volumes of business.) The investigator will pull records and look at your details. Do you have a large number of visually necessary billings that are right on the edge (just barely qualify as anisometropia)? Are you billing the maximum allowable? Are patients with two plans (such as Oracle) being billed on both plans for what appears to be the same lenses (e.g. you are not coordinating benefits under the COB rules)? Any of these, and many more "unusual" billing patters are likely to lead to a surprise, unannounced, in-office audit of your records.

Document Your Fitting Process


cl-fittingWhile you cannot easily prevent an audit, to prevent being found lacking in documentation it is essential that have a separately identifiable area in your patient record where you thoroughly document the contact lens fitting and dispensing process, even for return patients for whom you are only reordering lenses, perhaps with a new prescription or perhaps not even that. At a minimum, your chart's contact lens record and fitting section should have the following information recorded somewhere for each visit that you are billing to VSP for a "fitting" or other contact lens-related professional fees (but see the VSP requirements detailed below for more specific VSP requirements):

  • The materials/CL type dispensed, including the number of lenses dispensed;
  • The prescription dispensed;
  • The wearing schedule and the lens replacement schedule;
  • The recommended care/cleaning;
  • Fit evaluation/comments;
  • VA through the lenses and/or overrefraction; and
  • The date the lenses were dispensed.

While certainly this information needs to be there for a new fit, this is true even for the annual replacement contact lens "fit." You may do nothing more than dispenses some boxes of lenses. Write it down. Write the lens type, the Rx, the wearing schedule, the replacement schedule, the care plan, and, most of all, "CL dispensed from inventory" so that there is no question when the auditor reviews the chart that CL services and materials were provided, and what was done.

 

VSP is not in the business of giving you the benefit of the doubt. They ascribe rather strictly to the, "if you don't write it, you didn't do it" rule. Records that do not clearly document that lenses were dispensed have become a recent target of VSP audits, often resulting in large restitution demands and even removal from the VSP panel.

Actually Dispense the Lenses


Another trap is when the patient asks you to order everything the patient's benefits will cover, in order to obtain the maximum benefits, but has you "hold" or keep a credit for the lenses the patient doesn't need right now. VSP does not putting-cl-in-eyeallow this. You must dispense what you have billed to VSP. Also, if the patient ends up NOT ordering contact lenses (for whatever reason) and you've billed it already, you MUST contact VSP provider relations and let them know so that they can adjust your payment. If you get paid for a CL fit and lenses, the patient record must show that you performed a fitting or evaluation, and that the patient has the lenses. No matter the reason, if the patient does not have the lenses you billed for, you are at risk. The safe approach is to NOT bill VSP for contact lenses until the lenses are dispensed and the patient is happy. And, if anything changes, call VSP and tell them - and then DOCUMENT in your record what you did.

Charge Appropriately and Correctly

If you are audited VSP will try to obtain a copy of your office's fee schedule. They will then compare your regular fees (both fitting fees and material fees), presumably the fees charged to your non-insurance patients, to what you are charging VSP for the same services. Just because a patient's contact lenses are covered by VSP as "necessary" contact lenses does not mean you can charge more. VSP will pay more of the charge, but the charge should be what you ordinarily charge any patient.

A commonly seen audit problem related to necessary contact lenses is "overbilling for contact lenses." This happens when, for instance, you normally charge $50 for two boxes of spherical lenses, and $100 for a spherical CL lens fitting and follow up, and a VSP patient that is -2.00 OD and -5.00 OS comes in and is charged more. That's a qualified "necessary contact lens" patient. But it does not mean you can charge $80 for the lenses and $395 for the "medically necessary CL fitting." VSP will initially pay that full amount. But if you get audited you'll be found to be overbilling VSP. The difference between a NCL billing to VSP and an NCL billing to a patient is WHO is paying it, not HOW MUCH is being charged and paid.

Summary


Lack of adequate documentation is, by FAR, the single most common reason for adverse actions against doctors by VSP, followed by overbilling for NCL. If you don't write it down, you didn't do it. Remember that! And charge VSP patients what you'd charge a private pay patient for the same services and materials.

Unfortunately, VSP has said I can not reproduce their Contact Lens Fitting and Documentation guidelines (apparently they don't condone educating doctors on what their rules are!), so those rules can only be paraphrased here. Thus, here is a summary of the section in the VSP Manual on Contact Lens fitting and documentation as of August 1, 2012, but you should consult the on-line VSP manual for the precise VSP rules.

Contact Lens Fitting and Case Management

All CL patients fall into one of two groups:(a) First-time CL wearers or those being refit into new parameters or lens type, and (b) all others.

 

First-time contact lens wearers or contact lens refit patients can receive a "diagnostic contact lens fitting" (see below). When you do a "diagnostic fitting" it includes the contact lens history, evaluation/fitting services, your assessment, and your treatment plan. VSP defines "contact lens refittings" as those cases in which patients have worn contact lenses before but are being REFIT into a different parameter (e.g. different base curve, different diameter, etc.) or different type of contact lens (e.g. gas perm to soft, spherical to toric, extended wear to daily wear, etc.).

 

Patients that are not a first-time CL fit or a CL refit (e.g. new parameters or new CL type) are addressed under the "Routine Progress Evaluation or Subsequent Visit" rules below.

 

Procedures and Recording Guidelines For CL Patients

VSP requires the evaluation and record-keeping described in each area below.

A. Diagnostic Contact Lens Fitting Requirements
(Only Applicable to New Fits and Refits, See Below for All Others)

Contact lens history

Record whatever additional case history impacts the use and care of the patient's contact lenses such as their work conditions, desired wearing schedule, previous lenses, and the solutions they are using.

Fitting and Evaluation of the Contact Lenses

Keratometry followed by slit lamp evaluation both:

With diagnostic contact lenses to assess fit (document the diagnostic lenses through which the tests were performed); and

Without lenses to assess the cornea, sclera, conjunctiva, lids, and/or tear film as indicated (be sure to record SOMETHING about the cornea and its health).

    Over-refraction

    Monocular VA with and without new lenses

    Subjective and/or doctor’s objective response to the diagnostic lenses

     

    *Note: Anterior segment photos will not be accepted in place of biomicroscopy without separate documentation of anterior segment findings.

    Assessment

    Record your clinical findings, impressions and diagnosis.

    Plan

    The treatment plan is related to the assessment and includes:

    Ordering information, such as lens material and parameter: base curve, diameter, power, peripheral curves, and thickness, when applicable.

    Verification of the the lens parameters, if applicable.

    At the time of dispensing record instructions for lens care, handling, and wearing schedule. Patients must demonstrate the ability to handle, insert, and remove the contact lenses.

    Maintain all records of financial data relating to contact lens materials, fitting, and management.

    B. Routine Progress Evaluation or Subsequent Visits
    (Applicable to All Others.)

    Contact lens History

    Relevant CL-related case history, including lens care and wearing/replacement schedule compliance

    Contact lens Evaluation and Fitting.

    Monocular acuities with new lenses

    Over-refraction, if appropriate

    Slit lamp exam with and without contact lenses

    Keratometry if/when indicated

    Assessment

    Record your clinical findings, impressions and diagnosis.

    Plan

    Recommendations and advice, including wearing and/or replacement schedule, and/or lens care

    Record of any CL-related financial transactions