VSP Questions Answered

The last board meeting the following questions were asked about VSP billing.
Jennifer Ong, OD (Board Member COA) was emailed the following.

Questions

1. Negative reimbursement for polycarb lenses concerning Healthy Families
2. Is VSP going to open provider panel to commercial optometry to increase exposure of their new Marchon line
3. Are diabetic exams reimbursable under VSP?

Answers (via email to Dr Ong)

Thanks for your e-mail and fax. VSP was closed for Thanksgiving. So, I didn't get some details regarding your questions until this morning. Let me answer them to the best of my ability:

1) This question requires some specific information from the doctor in question. When you say "Healthy Families", I assume you mean a RNP or Value plan. If the doctor can confirm the specific plan coverage, that would be helpful.
I will also need a copy of the doctor's EOB (Explanation of Benefits) from VSP as well as a copy of their lab bill. VSP will then contact the doctor directly, on a case by case basis.

I have fielded a couple of these concerns in the past. They both posted profits for the doctor, once calculated correctly. The two most common miscalculations in these cases have been as follows:

a) The doctor forgets to collect or calculate appropriate co-payments in their profit/loss analysis
b) The doctor does not utilize a laboratory from the list of VSP labs that have agreed to provide these lenses at the discounted pre-negotiated rate

If you send me the requested information, I will be happy to forward the information to the appropriate VSP representative.

2) No, there is no intention to change the requirements for becoming a panel doctor as a result of the Marchon acquistion. The purchase of Marchon is a vertical integration strategy to strengthen VSP's position in the marketplace and provide a greater benefit to it's network doctors and clients.

3) I'm not 100% sure how you are defining a "diabetic retinopathy exam"? VSP already follows the AOA guidelines of practice for diabetics. This requires an annual dilated fundus exam. If a dilation is not performed during the annual wellness visit for a VSP patient, then it should be documented where this dilation is taking place (ie: with an OMD). If you mean additional visits for more frequent checks, or additional services such as fundus photography, then there is an order of billing. Additional medical services should always be billed to the major medical of the insured first. If you are unable to bill the major medical, and the patient has Primary Eyecare (PEC), then PEC can be billed for the additional services. As of January 1st, VSP will be providing Diabetic Eyecare (DEC) - See explanation below. However, this only applies to Type 1 Diabetics and will only be offered in conjunction with Signature VSP plans that don't already have PEC. Does that answer this question? If not, let me know more details.

Hope that helps. If you need further assistance, e-mail is usually the easiest and my cell phone would be next 9925) 872-4221.

(Signed James Winnick)

Also included

Eligibility & Authorization Patients don't need a primary care doctor referral before their first visits. Patients can make appointments or be seen immediately. Check eligibility before providing services. Refer ineligible patients back to their medical primary care doctors. Patients choosing to get services without checking eligibility should sign the Patient Responsibility Statement. It's available on VSPOnline on eyefinity.com. Patients without required primary care doctor referrals should also sign this statement.
Copay A $5 patient copay is required for exams and consultations only.
Coordination of Benefits Coordination of benefits (COB) applies to the payment of medical eyecare benefits when a member is covered under two or more benefit plans. If a member has medical benefits under another plan that you're contracted with, that plan is primary and VSP is secondary. You're responsible for verifying other coverage, as well as billing and collecting from the other carrier(s).
Tamiko Moon
Practice Account Manager
| Provider Relations
| 3333 Quality Drive, Rancho Cordova, CA 95670 vsp.com
| P: 916.851.4677 or 800.852.7600 x 4677
| F: 916.858.5330 or 888.877.1254