Healthcare

AI-enabled ambient listening tools are rapidly gaining traction in healthcare settings around the world. These solutions can significantly reduce provider documentation time, capture more complete information from patient encounters, and free up clinicians to spend more meaningful time face-to-face with patients.

However, like any emerging technology, these tools introduce risk. Healthcare organizations should carefully evaluate these tools and maintain strong oversight to ensure accuracy, privacy, and compliance.

Below are key takeaways Dean Dorton’s Healthcare Internal Audit team has identified when reviewing these tools and analyzing encounters generated with AI transcription.

Be Proactive – Provide Tools Before Providers Find Their Own

Physicians can be eager adopters of tools that enhance productivity and care quality. If your organization isn’t actively identifying and vetting ambient listening technologies, providers may seek out unsanctioned tools on their own.

This can lead to serious concerns about patient privacy and data security, especially when tools fall outside your electronic health record environment.

Review Retention Policies and Storage Practices

Understand what form patient interaction recordings take and how long they are stored.

Short retention windows or audio-only storage formats may limit your organization’s ability to validate whether AI-generated documentation accurately reflects the encounter.

Monitor Templates Used in Documentation

Ambient listening tools often generate documentation using predefined templates that may include elements such as a physical exam.

In some cases, the physical exam field may auto-populate with standard “healthy” terminology since these details are rarely spoken aloud. Ensure providers carefully review and update template fields so records accurately reflect the patient’s true condition.

Scrutinize Medication and Prescription Details

Medication names are a frequent challenge for AI transcription tools. Slight errors in recognition can lead to documentation or prescribing inaccuracies.

Provider diligence is essential to confirm that the medication names, dosages, and instructions are correct before finalizing the record.

Require Hard Stops for Reviewing Orders

Depending on training data, AI tools may incorrectly substitute diagnostic test names when generating suggested orders.

Implement a mandatory review step (a hard stop) for providers to verify all AI-generated suggested orders before approval to prevent incorrect or inappropriate orders from being placed.

Educate Providers on Common Pitfalls

Beyond the specific concerns pointed out above, providers should be on the lookout for other situations that can result in the tool producing inaccurate medical record information, namely:

• When a family member or companion joins the conversation and contributes information
• When irrelevant or off-topic dialogue occurs during the visit
• When recording continues after the encounter ends, potentially capturing details about another patient and misplaces them in the record.

Wound care providers are currently facing growing challenges with payer coverage and reimbursement for skin substitutes used in chronic wound treatments. These products have come under close examination due to concerns over clinical efficacy, inconsistent evidence, and increased regulatory and fraud investigations. As a result, agencies like the Center for Medicare and Medicaid Services (CMS) and the Department of Justice (DOJ) are increasing oversight to ensure medical necessity, appropriate use, and ethical practices among manufacturers and providers.

What’s Driving the Increased Oversight?

Several key factors have prompted closer review of skin substitute use in wound care:

• Limited evidence
• Regulatory confusion
• High costs
• Faud investigations

Together, these issues have made it more difficult for providers to navigate payer policies and secure reimbursement.

Reasons for increased scrutiny include a lack of robust clinical evidence supporting outcomes, limited product evidence for certain wound types, improper marketing or misunderstood regulations regarding the use of human cells, tissue, or cellular or tissue-based products (HCT/Ps), and increased regulatory oversight to ensure these products are used appropriately. In addition, the high cost of skin substitutes is a major concern, and there are ongoing debates about whether the current evidence justifies the expenditure.

The Impact on Providers and Patients

Many payers have released coverage and reimbursement policies specific to the use of skin substitutes for diabetic foot ulcers and venous leg ulcers. However, providers often face uncertainty when using these products for other types of chronic wounds.

This ambiguity can lead to:

• Increased audit and claim denial risk
• Delays in reimbursement
• Potential loss of patient access to effective treatments

Without clear guidance, providers may face inconsistent payer decisions that disrupt care delivery and financial stability.

Evolving Guidance from CMS and Other Agencies

The good news is that agencies like CMS are working on clearer policies for coverage and reimbursement to ensure patients continue to have access to appropriate, high-quality wound care products.

In the meantime, providers should:

• Review each payer’s documentation and medical necessity requirements closely
• Maintain detailed clinical notes supporting each skin substitute application
• Ensure compliance with all regulatory and billing guidelines

Diligent documentation and proactive compliance are the best defense against denials and audits.

How We Can Help

Recent fraud investigations and reports from the Office of Inspector General (OIG) have led to increased oversight of skin substitute billing, making expert review critical for healthcare providers.

If you need help in navigating wound care skin substitute scrutiny, Dean Dorton can provide guidance on compliance, documentation, medical necessity, and cost-effective utilization.

Contact one of our experts now.

Aetna, one of the Nation’s largest Medicare Managed Care Organizations (MCOs), has announced a significant change to its inpatient payment policy, set to take effect November 15, 2025. This update, known as the “one midnight” rule, has the potential to impact hospital reimbursement and increase administrative burdens for healthcare providers.

What’s Changing?

Under the new policy, when a patient is admitted to a hospital from the emergency department or urgent care setting, Aetna will automatically approve the inpatient status without conducting a medical necessity review. 

However, while the admission will be approved as an inpatient, Aetna will pay the claim at an observation rate rather than an inpatient rate. The difference is significant – observation rates are typically far lower than inpatient reimbursement rates, leading to potential underpayments for hospitals.

The Financial and Operational Impact

This shift poses several challenges for hospitals and health systems:

• Lower reimbursement: Claims that qualify for inpatient payment may instead be paid at the observation level, creating a reimbursement gap.
• Administrative burden: Hospitals will need to identify cases where stays exceed “one midnight” and ensure timely appeals to recover underpayments.
• System limitations: Many billing systems may not be equipped to automatically flag these payment downgrades in real time.
• Potential for missed appeals: In many cases, discrepancies are discovered later by underpayment review vendors – often after the appeal window has closed.

For hospitals with a high volume of Aetna patients, this “one midnight” change could lead to significant revenue loss unless proactive measures are taken.

Will Other MCOs Follow?

A key question remains: Will other Medicare Managed Care Organizations adopt a similar approach?

If additional payers follow Aetna’s lead, hospitals could face even greater challenges in monitoring and managing these reimbursement downgrades across multiple systems.

What Hospitals Can Do Now

Hospitals should begin preparing now for Aetna’s policy change. Recommended actions include:

1. Review current processes for identifying observation versus inpatient payment discrepancies.
2. Work with billing teams and vendors to ensure systems can flag stays exceeding one midnight for review.
3. Monitor Aetna claims more frequently to allow enough time for appeals, rather than relying solely on post-payment audits.
4. Communicate with Aetna representatives to clarify how the change will be implemented and how appeals should be handled.

Staying Ahead of Change

As payer policies evolve, staying proactive is key to protecting your organization’s revenue. Dean Dorton’s healthcare consulting and reimbursement teams help hospitals navigate complex payer changes, optimize billing processes, and recover lost revenue.

If you’d like to discuss how this change may affect your organization or explore strategies to safeguard reimbursement, contact Dean Dorton’s healthcare team today.