Quality Assurance Program
Program Overview
VSP's Quality Assurance Program supports the delivery of safe, effective, patient-centered eye care across the provider network. Through the evaluation of clinical performance, quality outcomes, and medical record documentation, the program promotes continuous quality improvement, evidence-based practice, and excellence in patient care. Program activities are conducted in accordance with applicable regulatory, contractual, and accreditation standards, including those established by the National Committee for Quality Assurance (NCQA).
Medical Record Submission Requirements
VSP conducts quality assurance medical record reviews through a secure electronic review process. If selected for review, the VSP Quality Management Department will send a request to your email address on file identifying the patient records requested, response timeframe, and instructions for securely uploading records and completing the required records attestation.
Clinical peer reviewers evaluate records using VSP's clinical and documentation standards, applicable policies and procedures, and nationally recognized clinical practice guidelines, including those established by the American Optometric Association (AOA) and the American Academy of Ophthalmology (AAO).
Please submit complete, legible, and accurate copies of the requested medical records for the identified dates of service. Documentation should support the clinical evaluation, diagnosis, management, and treatment provided and include all information necessary to accurately reflect the care rendered. Records should be submitted in their original form.
If a medical record contains an amendment, correction, addendum, or late entry, the original documentation should remain identifiable. Any additional entry should clearly indicate the date of the entry, the author, and the reason for the modification, consistent with accepted medical record documentation practices.
Quality Assurance Review Process Overview
VSP may conduct quality assurance medical record reviews at any time during a provider’s participation in the VSP network. Reviews generally consist of up to ten randomly selected VSP patient records associated with claims submitted under the provider’s name. Records identifying another practitioner as the provider who performed the examination will be excluded from review and may affect the overall review outcome.
Qualified clinical peer reviewers evaluate records using VSP's clinical and documentation standards. Providers receive written notification of review results, including confirmation of compliance and, when applicable, opportunities for improvement.
The review process promotes continuous quality improvement through an educational and collaborative approach. When opportunities for improvement are identified, VSP partners with network doctors and their staff by providing education, guidance, resources, and quality support to strengthen documentation practices, support adherence to established standards of care, and promote positive patient outcomes.
Review Levels
VSP uses a progressive review process that provides network doctors and their staff with clinical peer feedback, education, and time to address identified opportunities for improvement. If additional quality reviews are needed, each stage is intended to evaluate whether the recommended improvements have been incorporated into the provider’s documentation and clinical workflows.
Level I — Educational Review
The Level I Educational Review is a routine quality assurance review conducted for network doctors with an established volume of VSP claims. The review evaluates medical record documentation and clinical care against VSP's quality and documentation standards to support the delivery of high-quality patient care.
When the review findings meet VSP's standards, no additional review activities or financial assessment will result from that review. Network doctors remain eligible for future reviews as part of VSP's ongoing Quality Assurance Program and commitment to continuous quality improvement.
When opportunities for improvement are identified, VSP will provide individualized feedback, educational resources, and guidance to support documentation and clinical recordkeeping best practices. In these instances, a Level II First Formal Review is generally scheduled within six months. This interval provides sufficient time for providers and their staff to incorporate recommended documentation enhancements, strengthen workflows, and consistently apply updated recordkeeping practices.
The follow-up review is designed to assess the effectiveness of these improvements, reinforce quality standards, and promote accurate, complete, and clinically accurate documentation. Through this process, VSP partners with network doctors to support continuous improvement, regulatory readiness, and the consistent delivery of safe, high-quality patient care.
Level II — First Formal Review
The Level II First Formal Review is conducted when opportunities for improvement identified during the Level I Educational Review require follow-up evaluation. A new sample of VSP patient medical records is reviewed to assess whether recommended documentation enhancements and quality improvement measures have been successfully implemented and whether the records meet VSP's exam and documentation standards.
When the review findings meet VSP's standards, no additional review activities or financial assessment will result from that review. The doctor will be considered in good standing for purposes of the review process and will remain eligible for future reviews as part of VSP's ongoing Quality Assurance Program and commitment to continuous quality improvement.
When opportunities for further improvement are identified, VSP may assess up to $100 for each record with documented deficiencies. VSP will provide individualized feedback, educational guidance, and a corrective action plan to support continued improvement. In these instances, a Level III Second Formal Review is generally scheduled within three to six months.
Level III – Second Formal Review
The Level III Second Formal Review is conducted when opportunities for improvement identified during the First Formal Review require additional follow-up evaluation. This is the final review level in the VSP’s quality assurance review process and provides an additional opportunity to demonstrate compliance with VSP’s quality and documentation standards.
A $500 re-review fee is assessed and collected at the time of the Second Formal Review.
When the review findings meet VSP's standards, no additional review activities or financial assessment will result from that review. The doctor will remain eligible for future reviews as part of VSP's ongoing Quality Assurance Program and commitment to continuous quality improvement.
When the review identifies continued deficiencies, VSP may assess financial penalties for records with documented discrepancies based on the doctor's claim volume during the preceding 12 months. VSP will provide detailed findings and may implement additional quality improvement measures, including enhanced monitoring, individualized corrective action requirements, or a recommendation regarding continued VSP network participation, consistent with applicable provider agreements, policies, and procedures.
This final review level is intended to evaluate the effectiveness of corrective actions, assess sustained adherence to quality and documentation standards, and support the consistent delivery of safe, effective, and high-quality patient care throughout the VSP network.