When O&P practices stay quiet about compliance problems, patients are the ones who find out

If your prosthetic claim goes into prepayment review, you will wait longer for your device and may end up responsible for a bill the practice cannot collect. Most patients who reach that point don’t know what sequence of small decisions inside the practice got them there.

A column published this week in The O&P EDGE names the sequence.

Scott Williamson, MBA, CAE (ret.), president of Quality Outcomes and executive director of education and events for OPIE Software, wrote a practice management piece aimed at owners and clinicians of small O&P practices. The argument is about communication culture: what happens in a practice of nine or fewer people when the people who know about a problem say nothing. The piece is aimed at practitioners, but the specific failure modes it names are ones patients end up on the receiving end of.

What the patterns look like inside a small practice

In a small practice, Williamson argues, there’s no institutional structure to absorb silence. If someone knows a process has slipped and says nothing, the slip continues. The front desk stops verifying benefits at check-in and keeps skipping it. A technician drops a fabrication checklist step and keeps dropping it. A referral source sends incomplete orders and keeps sending them. No alarm goes off. The problem just runs.

Each of those failures has a direct consequence for the patient.

Unverified benefits mean a patient may be told coverage exists or that a deductible is met when neither has actually been confirmed. That surfaces as a surprise bill after delivery. At that point, the options for reversing it are limited.

Skipped fabrication checklist steps are harder to trace. The chart usually doesn’t record what was omitted. If a fit problem or skin breakdown follows, the record won’t show what step was missed or by whom.

The billing shortcut with the worst odds

Williamson spends the most time on one specific pattern: reaching for the ST modifier when the clinical record doesn’t support it.

The ST modifier signals to Medicare that a prosthetic delivery was medically urgent, which bypasses the prior authorization requirement. For genuine emergencies, it’s appropriate. As a workaround for inconvenient authorization timelines, it’s a problem with documented consequences.

The American Orthotic and Prosthetic Association (AOPA) has found that claims using the ST modifier draw Medicare prepayment review about half the time when the clinical record doesn’t back the urgency claim. Prepayment review holds the claim before payment while the insurer examines the record. If the documentation doesn’t support the modifier, the claim is denied.

For a patient, that timeline means the device was already delivered before the review happened. If the claim is denied after delivery, the practice absorbs the cost of the device or attempts to bill the patient. Whether the patient is actually liable depends on the circumstances, but the dispute is now yours to navigate.

Williamson calls this category of decision a one-way door. You cannot un-deliver a device. Whatever was in the documentation at the time of delivery is what an appeal has to work with. If the chart was abbreviated because no one in the practice wanted to push back on the timeline, the appeal starts short.

Why this happens

The column draws on research to explain the mechanism, and it’s worth understanding because the pattern shows up in O&P specifically around referral relationships.

UCLA neuroscientist Naomi Eisenberger’s research found that social rejection activates some of the same neural pathways as physical pain. Kahneman and Tversky’s work on loss aversion adds that the more someone has invested, the more a difficult conversation feels like a threat to what they’ve built. James Detert at the University of Virginia found that people in organizations consistently overestimate what will happen when they speak up, and underestimate what staying quiet costs.

The specific fear Williamson names for O&P is losing a referral source. Telling a physician’s office their documentation won’t survive a CMS audit feels like putting that referral stream at risk. So practices absorb the rework, fix it on their end, and say nothing. Two years of that, and the office has no reason to do anything differently. The cleanup has become someone’s unofficial job.

What this means for patients

There’s no way to audit a practice’s internal communication culture before you’re in it. But a few questions are worth asking, either before you commit to a practice or after a claim has gone wrong.

Before your evaluation: ask whether your specific insurer’s coverage for your functional classification has been confirmed for this visit. A practice that handles authorization well has a clear answer to this.

After a denial: you have the right under HIPAA to your clinical records, including the documentation submitted with your claim. If the denial cites insufficient documentation of medical necessity or references a prepayment review flag, it’s worth looking at what was actually in the chart and comparing it against what your insurer said was missing.

If your claim used an urgent delivery modifier and you were not in a clinical emergency at the time: ask the practice what modifier was used and what documentation supported it. That is a reasonable question to ask.

Most of the patterns Williamson describes come from structural avoidance inside the practice, not individual bad decisions. Knowing what questions to ask and what documentation you’re entitled to see doesn’t change what happened, but it gives you something to work with when you’re deciding whether to appeal or where to go next.

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This article describes general billing patterns and patient rights under existing law. It is not legal, insurance, or benefits advice. If you are dealing with a specific claim denial, contact your insurer’s member services line or a patient advocate who specializes in healthcare billing.