When a practice avoids the hard conversation, patients often end up holding the denial

A management column by Scott Williamson in O&P EDGE this week targets practice owners and clinical directors. It covers why capable people in small O&P offices avoid the conversations they know they should be having: with their own staff, with referral sources, with practitioners who are cutting corners in documentation.

The piece is worth reading if you’re a patient in the O&P system, because Williamson names the specific decisions where internal silence produces outcomes that land on you.

Why it’s hard to speak up in a small practice

Williamson draws on research from UCLA neuroscientist Naomi Eisenberger, who found that social rejection activates some of the same neural pathways as physical pain. The avoidance reflex isn’t a character flaw. It’s a nervous system response that, without intervention, the brain applies to uncomfortable workplace conversations the same way it applies to physical threat.

Research from University of Virginia’s James Detert adds a specific finding: leaders consistently overestimate what will actually happen when they speak up, and consistently underestimate the cost of staying quiet. The feared consequence usually doesn’t materialize. The unreported problem keeps accumulating.

In O&P practices, Williamson writes, the specific fear is usually about referral relationships. A physician’s office that sends incomplete documentation creates rework. Telling them directly feels like risking the referral stream. So the practice absorbs the rework and says nothing. “And the cleanup has quietly become somebody’s job description.”

That absorbed rework is usually something in your record or your claim.

Two categories of decision

Williamson uses a framework from Jeff Bezos to sort practice decisions into two types.

Most are reversible: who checks insurance eligibility at check-in, when in the week to schedule deliveries, how to run a morning huddle. If these go wrong, you can change them.

Two are not.

Delivering a device before the documentation supports it. You cannot un-deliver. If the claim documentation doesn’t survive payer review, the denial arrives months after the fitting, after you’ve been using the device, and after the practice’s leverage to address it has narrowed. The device is yours. The denial is also yours to navigate.

Using the ST modifier when the clinical record doesn’t support it. The ST modifier signals that a device is medically necessary without prior authorization because waiting would harm the patient. Williamson cites an AOPA finding that ST modifier claims draw prepayment review about half the time. A practice that uses the modifier to avoid prior authorization friction, rather than to document genuine medical necessity, is taking a documentation risk that shows up as a review on your claim.

Both of these shortcuts are more likely in a practice where the person who noticed the issue didn’t say so.

What to watch for

You’re not in a position to audit a practice’s internal culture before starting care. But some things become visible over time.

A practitioner who rushes to delivery before prior authorization is complete may be genuinely protecting your access to timely care. That’s what the ST modifier exists for. The question worth asking, if a claim is later flagged for prepayment review, is what the medical record showed at the time. Was the urgency documented?

If a claim denial arrives well after device delivery, the documentation from the time of delivery is what matters. You have a right to request an explanation of benefits and to ask your practitioner what the supporting record shows.

Williamson frames this as a structural problem, not a misconduct problem. Capable, careful people in small offices make decisions that create downstream harm, not from indifference, but because the avoidance reflex is genuinely difficult to override in the moment. The front desk person who stopped verifying benefits at check-in didn’t set out to cause billing problems. They rerouted around a conversation that felt uncomfortable, and the omission compounded.

Most of what goes unsaid in a practice is reversible. The hard conversation about referral documentation, the check-in process change, the fabrication checklist: you can walk back through those if the first attempt goes wrong. The device delivered without the right documentation is a different category. You can’t walk that one back.

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Based on “Nobody Gets Fired for Saying Nothing” by Scott Williamson, MBA, CAE (ret.), O&P EDGE, October 12, 2026. This article does not describe any specific practice or practitioner. For questions about your own claims, documentation, or denial status, contact your O&P provider and your insurer directly. Amputee News does not provide individualized billing, legal, or benefits advice.