By Thu T. Pham, O.D., J.D., The Health Law Firm
Unannounced guests dropping by can be a stressful experience for a surprised host. Many would agree that the worst unannounced visitor of all, dreaded more than the in-laws, is the auditor. This “guest” is looking to scrutinize your office policies, patient records, and billing files to uncover and prove allegations worthy of disciplinary action. Optometrists and ophthalmologists have very different audit experiences in comparison to other types of healthcare professionals. Third party payers, typically Vision Service Plan (VSP), perform the audits of vision care practices. Warning: These third party payers have recently increased the frequency of such audits. Below is everything you need to know.
Types of VSP Audits.
Like most healthcare audits, the objective of VSP audits is to identify lapses in strict compliance of industry rules and regulations in areas such as billing, filing, and general business practices. However, unlike Medicare audits that take place only when there is a suspected issue or violation, VSP commonly performs routine audits to ensure quality control. Eventually VSP reviews each doctor about once every five years as required by the National Committee for Quality Assurance Standards. VSP rules change frequently without warning, so it’s critical to stay up to date on the latest compliance rules.
VSP audits can take place in two very distinct formats. The most common audit previously noted above is the routine quality control audit. A practitioner will be asked to send in a small number of randomly selected patient files. These files will be reviewed by the VSP Quality Control Unit that will issue a report of the audit results. If issues are noted in the audit, the results may include a corrective action plan identifying the necessary corrections required. These audits can be expected time to time for all practicing optometrists and ophthalmologists.
The second type of VSP audit is typically ordered when major patterns of inconsistency are noted in an initial quality control audit. A “targeted audit” is performed by the VSP Special Investigations Unit (SIU) and is almost always unannounced. The SIU investigator will show up at an office and request on average 30 to 50 records. These records are not randomly selected, but rather, are related to one or more areas of interest. These audits are conducted to prove violations when it is already believed, by VSP, that rules are being broken.
How to Avoid Negative Audit Results.
A targeted audit can be triggered by a multitude of red flags. Disgruntled employees who make a claim or a patient complaint can lead to a surprise in-office visit from a VSP auditor. In addition, many questionable billing patterns noted by an auditor during a routine quality control audit can spark curiosity for further investigation. Billing for services and products at a rate higher than surrounding area doctors, or at a rate higher than you traditionally have charged, are both red flags. Billing for a comprehensive eye exam and a routine exam on or near the same date will also stick out as potential fraud.
Auditors, in both a quality control audit and targeted audit, focus their scrutiny on the history, examinations, and medical decision-making parts of a patient record. For a doctor, it is beneficial to clearly and completely record the reason for a patient’s visit, their symptoms, and past health history.
Verify that you have recorded any and all tests and exams that were performed during the appointment. Auditors will argue that if you didn’t write it down, it didn’t happen. From our experience, the most poorly documented section of a patient’s record is the medical decision at the conclusion of an exam. It is very crucial to provide detailed statements in addition to a final diagnosis. This will show the auditor you gave sufficient consideration during the exam to conclude a diagnosis. The more documentation you have, the more defensible those records are in an audit. The number one reason an audit may have a negative outcome is due to missing or insufficient documentation.
The Auditor is Knocking at the Door. Now What?
During an audit, the single most important action you can take is to agreeably provide the auditor with ALL complete records related to their requests. The less you argue and defend yourself, the better. A common mistake doctors make during a VSP audit is not providing copies of all relevant information. Relevant information includes any and all information you have on a patient related to the services and materials provided. Do not make assumptions when it comes to what information the auditor needs. Give them copies of everything you have.
If you cannot locate necessary files required for the investigation, ask the auditor for a time extension and put this permission in writing. Do your best to locate these missing files. Patient charts you cannot find during an unannounced audit will be considered over billed. Also, ask the auditor for a copy of the list of patient records that were audited. Keeping track of what you provided the auditor is also important in legally protecting yourself.
The Aftermath of an Audit: What to Expect.
The results of your audit will be mailed to you in a letter. The letter will either give you notice that VSP is terminating your Network Provider Agreement, order that you pay restitution, or both. You may be offered a Consent Decree or a Corrective Action Plan. The Corrective Action Plan is self explanatory: you must agree to immediately cease the actions alleged in the audit. In a Consent Decree, you will receive a probationary time period in which VSP may decide to terminate you or not. In this time frame, you are also eligible for additional audits billable to you.
The letter will also explain the process of appealing the audit’s findings under the “Fair Hearing Plan.” You will only have 30 days to file an appeal. During the process, should your letter claim restitution payments, VSP will immediately start withholding all funds owed to you and apply it to the claimed restitution.
An appeal will be conducted through an administrative peer-review hearing before the VSP Quality Control Panel. Records of the audit will be reviewed once again, and you will have the opportunity to provide evidence and your own records in support of your defense. The board, consisting of three doctors selected by VSP, has the authority to overrule the initial ruling. They may revise the restitution owed, repeal the termination, or initiate another form of disciplinary punishment. It is extremely difficult to convince this panel for an appeal. Should you lose an appeal, you still may seek arbitration or legal action in court.
Ideally, it is best to have an attorney familiar with you and your business available before any audit is initiated. An experienced health law attorney armed with knowledge of industry laws can be critical in successfully surviving the audit process. Any negative VSP action is typically reported to the National Practitioner Data Bank (NPDB) and will remain on your professional file for life. You may also be reported to the Board of Optometry which can lead to disciplinary action against your license. Securing a health law attorney who is familiar with the process is invaluable when considering the potential harm a negative VSP audit can cause.
Have you ever had experience with a VSP audit? Please leave any thoughtful comments below.
Contact Health Law Attorneys Experienced in Handling VSP Audits, Investigations and other Legal Proceedings.
The Health Law Firm’s attorneys routinely represent ophthalmologists, optometrists or other health professionals in VSP investigations, audits and recovery actions. We also represent optometrists, ophthalmologists and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the DEA, Department of Health (DOH) and other law enforcement agencies.
To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.
About the Author: Thu T. Pham, O.D., J.D., is an attorney with The Health Law Firm, which has a national practice. It’s main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
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