Dangers of the Unwritten Standard

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By Erin Cammarata

The topic for this article came to me like most do: saw a trend in my practice. I came across several "unwritten standards" at O&P practices in one week.

When clients call us for advice, I always ask, "What is your standard process or protocol for dealing with a situation like this?" Invariably the answer is, "We don't have one." They often say something like, "Well, I previously instructed the employees to handle it a certain way, but it just doesn't stick for longer than a few days."

This is how your practice develops unwritten standards.

Without written standards, processes, and procedures to follow, your staff will have to make up their own. What they create may not be satisfactory to you, but the simple fact is that we get what we tolerate. Business managers and owners may tolerate unwritten standards until we're forced to address them—like when Medicare gets involved or you lose a referral source.

Here are some examples of problems that arose due to a lack of written standards at O&P practices:


Inadequate Documentation

The O&P practice was consistently failing audits due to missing or incomplete medical records. There was no written standard for obtaining compliant documentation from the referral sources or for the timelines for the practitioners to complete their documentation. The unwritten standard for this practice was that it was okay to deliver items with an incomplete medical record on file.


Interdisciplinary Relationships

The O&P practice was losing referral sources due to negative interactions with the administrative staff. There were no written procedures for corresponding with referral sources. The unwritten standard was that it was acceptable to be discourteous and dismissive of the referral source's office staff, which cost this practice valuable relationships.


Inconsistent Utilization of Medical Software

The O&P practice had very little documentation of its collections activities in the software system because most of it was being kept externally. There were no written procedures for the collections process or documentation standards. The unwritten standard for this practice was to not document the collections actions on the claim, therefore creating no record of activity.

These processes became unwritten standards because they were tolerated for so long. The consequences associated with inconsistent unwritten standards can be devastating, but the questions beg to be asked:


  • Is it the employee's fault that the audit came back as unfavorable when the documentation provided to Medicare has been the company's unwritten standard for years?
  • Is it the employee's fault that claims have been billed without collections follow-up when there are no written procedures to follow?
  • Is it the employee's fault that the patient accounts receivable is creeping up when there are no written procedures for collections?


You do not need detective skills to see where I am going with this. It is our responsibility as the business owners and leaders to create the standards for our businesses and ensure that our teams are adhering to them.

When problems arise, look at it as a gift: It is an opportunity to create a written protocol to handle the situation more effectively next time. This can then become your new standard and will come to define your practice.


Erin Cammarata is president and owner of CBS Medical Billing and Consulting. She can be contacted at erin@cbsmedicalbilling.com.