VSP Greivance/Rant - OC Heights for Lined Segment Multifocals

[KrystleClear]

So, I have been taking Uuniverty's (A VSP continuing education resource) ABO prep class via Zoom on Wednesday nights. I am grateful for the free education, honestly. However, there have been a few instances of them giving us wrong or misleading information which they later corrected but was annoying because I studied and memorized what we were told and then having to re-learn it the correct way was confusing. Anyway, that's not the issue this time. The instructor is great though, and I have learned a lot. I'm sure it's not easy jugging two LIVE classes a week.

In last night's class, our instructor said that we should always be specifying optical centers on all lens orders, even ones with lined segments like flat top 28 or trifocals. I found this interesting because I knew from experience that VSP's claim submission website WILL NOT allow you to specify both a segment height and an optical center height. It spits out an error message and won't let you move forward until you correct it. I mentioned this in the chat for the Zoom meeting and the VSP employee who monitor's the chat chimed in and basically said I was lying. That that is absolutely not true and she knows because she works in claim submission and even so, we can always input special instructions. I think we all know how awful and clunky VSP's website is and how frustrating dealing with their provider customer service can be. I know from past experience that VSP will apply a chargeback to the claim for adding a special instruction. I once got a chargeback for writing in the special instructions that the patient had LASIK and wanted to use their plano sun benefit for LASIK patients. They dinged for a $10 chargeback (they call it a "Technical Add-on copay") for adding a special instruction, which is frustrating because the margins are already so slim with our VSP claims. And to contest it is a nightmare. Every time I have to call customer service for a problem, I end up getting transferred from person to person or I get told it's not their problem and to just suck it up basically. There was one time that I had a pediatric patient, who was only 7, but VSP refused to cover polycarbonate for them because they had him listed as a "student" and not a "child dependent." We ate the cost on that one because I'm not going to make the patients pay for VSP's clerical error.

It just irks me because they were so adamant about me being wrong. I had a VSP claim to submit today so I tried to see if maybe I was wrong. It spit out that error message, which I screen capped below, excluding patient identifiers of course. I obviously want to be doing what is best for the patients but I don't want to be losing money on orders or incurring an extra cost for patients for something that shouldn't even be an additional charge.

I know most times it doesn't matter anyway because the lab will assume an OC at 5mm above the specified segment height, but still.

[drk]

I thought, in the main, that:

1. Distance OCs are pre-fabbed 4 mm above the seg line.
2. Seeing that most segs are fit 8mm below pupil center (I know, many of you use an anatomical landmark for seg height--WRONGLY!)...
3. ...therefore, with an 8 mm drop from pupil center for a seg height, you get the correct-ish 4 mm distance OC drop for the standard 8 degrees of panto.

Is this right? I think so.

[Kwill212]

I thought, in the main, that:

1. Distance OCs are pre-fabbed 4 mm above the seg line.
2. Seeing that most segs are fit 8mm below pupil center (I know, many of you use an anatomical landmark for seg height--WRONGLY!)...
3. ...therefore, with an 8 mm drop from pupil center for a seg height, you get the correct-ish 4 mm distance OC drop for the standard 8 degrees of panto.

Is this right? I think so.

How(and why) would they prefab and OC height on a semi-finished FT blank? But otherwise yes, unless you are intentionally fitting fitting the seg line very low, or the frame fit is drastically out of normal, default is pretty good for most people.

[drk]

I don't know. I guess there isn't a prefab. I guess there's only a fab.

[Lensman11]

Traditionally the oc on a multi focal is placed in the geometric center of the frame as is in a Sv lens. There are occasions where you need to change that but it is rare so pay the the charge and be done with it. If you are doing that often you looking for issues that don’t exist. The reason some assume it is fixed at three or four above the seg line because that is where the majority of multifocals are fit three or four below geometric center.

[Hayde]

2. Seeing that most segs are fit 8mm below pupil center (I know, many of you use an anatomical landmark for seg height--WRONGLY!)...
3. ...therefore, with an 8 mm drop from pupil center for a seg height, you get the correct-ish 4 mm distance OC drop for the standard 8 degrees of panto.

Is this right? I think so.

Are you saying limbus and lower lid are both incorrect, or just one? If so which one? Is either wrong to any degree greater than an assumption of 8 degrees of panto? (You threw down the gauntlet to Brooks and Borish here, Doc. At least, I think you did?)

[Uncle Fester]

I thought, in the main, that:

1. Distance OCs are pre-fabbed 4 mm above the seg line.
2. Seeing that most segs are fit 8mm below pupil center (I know, many of you use an anatomical landmark for seg height--WRONGLY!)...
3. ...therefore, with an 8 mm drop from pupil center for a seg height, you get the correct-ish 4 mm distance OC drop for the standard 8 degrees of panto.

Is this right? I think so.

Me: "Are you comfortable where the seg heights you have now are?"

"Yes"

Matched and done

No or if it's a first fit:

"Let me put a piece of cellophane tape on these to simulate where the line will be and see if it's comfortable."

Picky patients get an OC placement but >99% are fine w/ the labs placement and I've never lost a minute of sleep over it.

[drk]

Are you saying limbus and lower lid are both incorrect, or just one? If so which one? Is either wrong to any degree greater than an assumption of 8 degrees of panto? (You threw down the gauntlet to Brooks and Borish here, Doc. At least, I think you did?)

I'm boring, so don't listen to me.

Since lids are so variable, I use the pupil center for a reference. In fact, I always use a split pd and dot the centers and do all the cognitive work later. Works for all kinds of everything, because that's the X and Y of the eye in the frame.

[drk]

Traditionally the oc on a multi focal is placed in the geometric center of the frame as is in a Sv lens. There are occasions where you need to change that but it is rare so pay the the charge and be done with it. If you are doing that often you looking for issues that don’t exist. The reason some assume it is fixed at three or four above the seg line because that is where the majority of multifocals are fit three or four below geometric center.

Oh. OK. Now I get it.

[NAICITPO]

Me: "Are you comfortable where the seg heights you have now are?"

"Yes"

Matched and done

No or if it's a first fit:

"Let me put a piece of cellophane tape on these to simulate where the line will be and see if it's comfortable."

Picky patients get an OC placement but >99% are fine w/ the labs placement and I've never lost a minute of sleep over it.

This.

I think I've specified an OC height on a bifocal maybe 3 times in 15 years dispensing. Geriatric folks with a higher Rx that I worry may fall down.

[NAICITPO]

And Krystle if you are worried about VSP doing a chargeback on changing an OC in the notes section, I would just call your lab after you submit the order and tell them to change it. That way VSP will be none the wiser.

[KrystleClear]

And Krystle if you are worried about VSP doing a chargeback on changing an OC in the notes section, I would just call your lab after you submit the order and tell them to change it. That way VSP will be none the wiser.

I'm so sick of VSP at this point. We allegedly are going to stop participating with it at some point. Which I welcome with open arms. I'm the only optician in my office and I don't want to have to spend any more time on hold with the lab or with VSP when I don't have to.

I guess what the instructor was saying is that we should always specify an OC measurement as well as a seg height for lined multifocals to avoid induced prism. I know that with one particular lab we use, the reps who answer the phone get weird if I even try to order flattops with monocular PDs (I had a patient with a significant difference in PDs between the right and left). The person who took the call at the lab tried to tell me that can't be done, but I know that's not true, especially since they "accidently" send me uneven bifocals when I specified a binocular near PD. Maybe I need reverse psychology with them. I can only imagine them getting annoyed when I also specify OC heights with the segs.

[NAICITPO]

I'm so sick of VSP at this point. We allegedly are going to stop participating with it at some point. Which I welcome with open arms. I'm the only optician in my office and I don't want to have to spend any more time on hold with the lab or with VSP when I don't have to.

Oh man sounds like you need a different lab. I call our main lab probably 10+ times a week to check on orders or to specify changes to an order/ do a Dr. redo. It takes me maybe a minute to get ahold of someone and get a problem like changing the OC fixed.

I guess what the instructor was saying is that we should always specify an OC measurement as well as a seg height for lined multifocals to avoid induced prism.

Your instructor is technically correct about specifying an OC on every lined multifocal. However, just think how high the Rx would have to be for the customer to even notice the yoked prism? It's been studied, under 2 diopters of yoked prism and not many people can even notice. Apply Prentice's rule and you would have to be off quite a bit in most Rx's to even get to 2 diopters. So like Fester said, don't lose sleep over it. And as Lensman11 said, if you are specifying an OC on a multifocal often you are looking for a problem that does not exist.

http://216.144.236.77/cecourse.php?url=prism_thinning/


So just how much yoked vertical prism is acceptable? That is, is there a limit to the amount of prism-thinning that a wearer can tolerate? A study was performed a few years ago exploring the effects of vertical yoked prism on wearer acceptance.* This study showed that a group of test subjects was not significantly affected by 2.0 Δ of vertical prism (and no significant postural adjustments were made). However, 4.0 Δ of vertical prism was rejected by almost all of the test subjects. Consequently, the limit of prism-thinning for most wearers will probably lie between 2 to 4 prism diopters.

* Sheedy, J. and S. Parsons. "Vertical yoked prism—Patient acceptance and postural adjustment." Journal of Ophthal. Physiol. Opt. Vol. 7 (1987), pp.: 255-257.

I know that with one particular lab we use, the reps who answer the phone get weird if I even try to order flattops with monocular PDs (I had a patient with a significant difference in PDs between the right and left). The person who took the call at the lab tried to tell me that can't be done, but I know that's not true, especially since they "accidently" send me uneven bifocals when I specified a binocular near PD. Maybe I need reverse psychology with them. I can only imagine them getting annoyed when I also specify OC heights with the segs.

Whenever a rep does that to me I just call back and talk to someone I know has been an optician longer than 5 minutes or I ask to speak with a supervisor. Seems to work well for me...

[Kwill212]

It's not just about yoked prism. Martin's rule applies to FTs just as it does to SV lenses.

[Elvis Is Alive]

I'm so sick of VSP at this point. We allegedly are going to stop participating with it at some point. Which I welcome with open arms. I'm the only optician in my office and I don't want to have to spend any more time on hold with the lab or with VSP when I don't have to.

I guess what the instructor was saying is that we should always specify an OC measurement as well as a seg height for lined multifocals to avoid induced prism. I know that with one particular lab we use, the reps who answer the phone get weird if I even try to order flattops with monocular PDs (I had a patient with a significant difference in PDs between the right and left). The person who took the call at the lab tried to tell me that can't be done, but I know that's not true, especially since they "accidently" send me uneven bifocals when I specified a binocular near PD. Maybe I need reverse psychology with them. I can only imagine them getting annoyed when I also specify OC heights with the segs.

Luckily, I no longer have to work with VSP. Here in Florida, insurances can't require use of an insurance owned lab. VSP's way around this was making VSP's own progressives and AR's "covered" in some plans where comparable same category products required a co-pay, essentially requiring you to use VSP's lab as almost no pt is willing to pay more for a comparable product. Needless to say, I'm happy to be out of that merry-go-round.

[NAICITPO]

Luckily, I no longer have to work with VSP. Here in Florida, insurances can't require use of an insurance owned lab. VSP's way around this was making VSP's own progressives and AR's "covered" in some plans where comparable same category products required a co-pay, essentially requiring you to use VSP's lab as almost no pt is willing to pay more for a comparable product. Needless to say, I'm happy to be out of that merry-go-round.

In our state we have always been able to choose what lab we wanted to send our VSP jobs to (hint we don't choose VSP). If I had to deal with VSP customer service I completely understand the frustration, really long wait times! I thought VSP got rid of forcing you to use their own labs?

https://www.optiboard.com/forums/sho...w-has-a-choice

[Elvis Is Alive]

Yes, they did that at almost the same time as reducing reimbursements 50% if you use a private lab. Not much of a choice if you ask me.