Healthcare Headaches

Rene Letourneau, for HealthLeaders Media , September 13, 2013
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"We are focused on clinical quality metrics," he says. "[We] monitor them monthly with our senior management team and have assigned accountability to the appropriate individuals. We are looking at the requirements from the various payers to qualify as centers of excellence and continue to improve our clinical programs and outcomes."

Tim Nguyen, corporate controller at Palomar Health, a 690-bed system based in San Diego, says the health insurance exchanges being established under the PPACA are a major obstacle for providers because of the uncertainty surrounding how they will operate once they are up and running.

"California is going to have a state-run exchange program. It is going to be a nightmare. We will have to decipher what plan the patient belongs to, which tier they belong to, their deducible, and copay. The state has no clue—they are just learning as they go along," Nguyen says.

Funding woes

Palomar is trying to meet the HIX challenges with increased revenue cycle automation, which will make it easier to determine if patients are eligible for insurance through the exchanges, get authorizations before procedures are performed to make sure the health plan will consider it medically necessary, and estimate patient deductibles and copays, Nguyen says.

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