Our Quality Assurance (QA) program partners with you to deliver the highest quality eye care to VSP patients. The program also educates you and your staff about our QA policies and procedures. This program follows state and federal regulations and guidelines from accrediting organizations like the National Committee for Quality Assurance (NCQA).

Medical record reviews involve an internal mail-in review or an on-site office review. QA requests only VSP patient records during these reviews. Electronic-record documentation is acceptable if findings are included. We use clinical peer reviewers trained in our policies and procedures to assess and grade reviews.

Patient medical records are submitted to VSP and reviewed by clinical peers who verify the exam and treatment for each patient follows established criteria and is properly documented.

Medical record reviews have up to three levels and may occur at any time. Each level requires ten, randomly selected VSP patient records. The patient names are chosen from claims billed in your name. A patient record with a different doctor noted as the one who performed the exam will not be reviewed and may impact the result of your review.

A peer reviewer accesses each record based on VSP’s exam and documentation standards and returns the results to the QA administrator who informs you of the review outcome. A QA contact name is provided and you may call at any time for clarification of the review results.

Educational Review (Routine Review)

The first review you’ll receive is a routine educational review. The review is assessed for a pass or non-pass and the results are communicated to you.

If you pass this educational review, no follow up review or financial assessment will occur.

A non-passing outcome will result in a First Formal review in approximately six months. This timeframe allows correction of the initial identified discrepancies.

First Formal Review

You will receive a First Formal review, requiring another ten VSP patient medical records, when you do not pass the prior educational review.

If you pass this First Formal, no follow up review or financial assessment will occur.

A non-passing outcome results in a financial assessment for each record with discrepancies at a maximum of $100.00. A Second Formal follow up review will occur in approximately six months. This timeframe allows the doctor to correct identified discrepancies.

Second Formal Review

You will receive a Second Formal review, requiring another ten VSP patient medical records, when you do not pass the prior First Formal review. This is the last review level to demonstrate you meet VSP’s exam and documentation standards.

A $500.00 fee is assessed and collected at the time of the Second Formal review.

If you pass this Second Formal, no other follow up review or additional financial assessment will occur.

Non-passing outcomes, at a minimum, lead to higher financial assessments for records with discrepancies based on the doctor’s 12-month claim volume and may result in a recommendation for possible contract termination from our network.