In Module One, our first step is to direct our focus on what healt
- 1. In Module One, our first step is to direct our focus on what healthcare reimbursement means and how that meaning will be applied throughout the course. In Module One, you will be provided with explanations of the terminology and methodologies surrounding the cost of healthcare services and, subsequently, how providers of those services are compensated. Reimbursement in a healthcare context refers to the payment that providers and facilities receive for the services that they provide their patients. Providers and facilities include physicians, hospitals, clinics, outpatient rehabilitation centers, home healthcare centers, and other healthcare facilities. Many providers are not-for-profit as opposed to investor-owned. Questions that will be answered in this module include: · What are reimbursement methodologies and how do they impact healthcare organizations? · What are the current trends in healthcare reimbursement? · How might healthcare administrators differentiate between reimbursement methods? · How are financial management principles applied to reimbursement methods? · Who are the key stakeholders surrounding healthcare reimbursement? The answers to these questions will provide you with a better understanding of the background, context, and trends surrounding healthcare reimbursement systems. Further, you will find it helpful to assume the role of a healthcare administrator as you practice what it would be like to assume a management position. Although you will have your own personal opinions based on experiences from a patient perspective, for this course, you will view the assignments through the lens of the healthcare administrator. The
- 2. administrator is challenged with providing the best care and services to the communities that they serve, while charging a price that is affordable to both the patient and the organization. The administrator must also take into account the various compliance standards and government regulations. Why Study Reimbursement? Healthcare administrators and other health personnel can better meet the needs of their patients, clients, and organization by offering clear guidelines and cost structures concerning healthcare reimbursement. The key stakeholders of healthcare reimbursement systems are patients, healthcare providers, and third-party processors. As such, there are many perspectives to consider when administrators develop strategic plans designed around revenue generation. Many healthcare administrators are involved in contract management decisions and also represent their organizations by negotiating with managed care organizations and third-party payers. The Affordable Care Act is one of the largest pieces of healthcare legislation in our era. The law itself is over 1,000 pages covering funding, Health Insurance Portability and Accountability Act (HIPAA) requirements, insurance coverage, health information systems, and reimbursement. Not surprisingly, this has contributed to the increase in employment in the healthcare industry. Employment in healthcare-related jobs is expected to rise by 22% over the next 7 to 10 years (Bureau of Labor Statistics, 2014). Hospitals account for approximately 39% of total healthcare employment (Bureau of Labor Statistics, 2014). Not surprisingly, there are career opportunities for those individuals entering the healthcare administration field. The study of reimbursement systems and methodologies provide students with knowledge needed to make management decisions impacting the revenue cycle. Consequently, management decisions impact the sustainability of the healthcare
- 3. organization. Financial Management and the Role of the Healthcare Administrator Financial management rests on theory, concepts, and tools that help managers make informed decisions. Therefore, in the context of reimbursement, healthcare administrators find themselves applying financial management principles to revenue cycle management. Healthcare information systems provide resource data that informs decision making (Stansfield, Walsh, Prata, & Evans, 2006). One source of financial data can be found in the general ledger system. Another source of data can be found in admission reports. Specific reports can provide information on the number of encounters (the number of patients that a doctor has seen). One example of an external report is a report on the number of aging individuals located in a geographical location. This information can be found on a state or government website (Centers for Medicare & Medicaid Services, 2015). Healthcare administrators use many sources of internal and external data to inform strategic, operational, and financial decision making. Next Steps In Module Two, you will examine healthcare reimbursement based on the reporting guidelines established by the Centers for Medicare & Medicaid Services (CMS). You will visit the CMS Website frequently in this course because of the vast amount of information that is provided on reimbursement, clinical coding, and other Medicare- and Medicaid-related topics. References: Bureau of Labor Statistics. (2014). Occupational outlook handbook. Retrieved from http://www.bis.gov/ooh/community- and-social-service/social-and-human-service-assistants.htm Centers for Medicare & Medicaid Services. (2015). Medicare. Retrieved from https://www.cms.gov/Medicare/Medicare.html
- 4. Stansfield, S. K., Walsh, J., Prata, N., & Evans, T. (2006). Information to improve decision making for health. In D. T. Jamison, J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, . . . P. Musgrove (Eds.), Disease control priorities in developing countries (pp. 1017–1030) (2nd ed.). Washington, DC: World Bank. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK11731 Harrisburg University ISEM 547 Vendor Management Objectives Vendor Management Overview Vendor Manager/VRM Vendor Management Best Practices Vendor Management Selection Vendor Managaement Framework 2 Vendor Management Overview
- 5. 3 What is Vendor Management? Vendor Management is a term used to describe the process of finding, qualifying and doing business with vendors. Common activities include researching vendors, negotiating contracts, obtaining quotes, evaluating performance, driving innovation and service excellence, creating and updating vendor files, and ensuring contract compliance (internal and external), work order, invoicing/billing, and payment approvals. 4 What does a Vendor Manager/VRM do?
- 6. Vendor Manager: (also referred to as vendor relationship managers) handle relationships with vendors and their company’s operational department. Organizations provide them with the authority and mechanisms to engage, govern, manage the relationship, optimize and to negotiate on behalf of their company for the best value of purchases that support its operations and business objectives. 5 What does a Vendor Manager/VRM do?
- 7. Manage the Relationship Contract Management Engagement Management Governance Oversight Multivendor Integrations Problem Management Driving Mutual Value Document Management 6 Vendor Management Success Tips & Best Practices 7 Vendor Management - Tips
- 8. Share Information and Priorities (Need to know basis) Balance Commitment and Competition Allow key vendors to help you strategize Build Long-Term Relationships Seek to Understand Your Vendor’s Business Too Negotiate a Win-Win Agreement Come Together on Value 8 Vendor Management – Best Practices Vendor Selection Scrutinize the Prospects Remain Flexible Monitor Performance
- 9. Communicate IT Management Framework 9 Vendor Management Vendor Management Selection Process 10 Vendor Management – Selection Process Analyze Business Requirements
- 10. Vendor Search - Request for Information (RFI) Request for Proposal (RFP) Proposal Evaluation & Vendor Selection Contract Negotiation Strategies 11 Vendor Management – Selection Process Assemble an Evaluation Team Evaluation Team – Define Needs & Requirements Define the Product, Material or Service Define the Technical and Business Requirements Define the Vendor Requirements Publish a Requirements Document for Approval 12 Vendor Management – Selection Process Evaluation Team – Vendor Search Compile a List of Possible Vendors Select Vendors to Request More Information From Write a Request for Information (RFI) Evaluate Responses and Create a "Short List" of Vendors 13
- 11. Vendor Management – Selection Process Select Evaluation Team Members & SMEs – Create Request for Proposal (RFP) Submission Details Introduction and Executive Summary Business Overview and Background Detailed Specifications Assumptions and Constraints Terms and Conditions Financial & Pricing (Separate from Technical Submission) Selection Criteria 14 Vendor Management – Selection Process Evaluation Team (Advisors & Voting Members) – Vendor Evaluation & Selection Preliminary Review of All Vendor Proposals Record Business Requirements and Vendor Requirements Assign Importance Value for Each Requirement Assign a Performance Value for Each Requirement Calculate a Total Performance Score Select the Winning Vendor 15
- 12. Vendor Management – Selection Process Specific Evaluation Team (Negotiators & Advisors) – Vendor Negotiations List Rank Your Priorities along with alternatives Know the Difference Between What You Need and What You Want Know Your Bottom Line So You Know When to Walk Away Define Any Time Constraints and Benchmarks Assess Potential Liabilities and Risks Confidentiality, non-compete, dispute resolution, changes in requirements Do the Same for Your Vendor (i.e. Walk a Mile in Their Shoes) Best and Final Offer (BAFO) 16 Vendor Management – Selection Process Other Considerations Legal Counsel Financial Viability Assessment & Financial Expert Logistics Authority to Negotiate 17
- 13. Vendor Management Establishing a Vendor Management Framework 18 Vendor Management Framework 19 Vendor Management Program (Mission & Objective) Leverage Best Practices Optimize External Spend Drive Innovation Rationalize Vendors Manage contract performance, relationship, and demand Improve Vendor Relationships Reduce Risk 20
- 14. Vendor Management Program (Org & Staffing) Determine the best organizational structure Determine the Staffing Requirements and Compliment Define the roles, duties & responsibilities Skill-sets & Competencies 21 Vendor Management Program (Value Metrics) Efficiencies Performance Relationship Quality 22 Vendor Management Program (Optimize Vendor Portfolio) Strategic Vendors Legacy Vendors Emerging Vendors Tactical Vendors 23
- 15. Vendor Management Program (Create Strategic Management Program) Develop a formal IT vendor management program, defining the organization, governance, and processes, and procedures necessary to effectively manage a multivendor environment in a comprehensive manner. Strategic vendor management is a discipline of managing those vendors that are most critical to the business and is intended to replace transaction driven or ad-hoc approach to vendor management. 24 Vendor Management Framework (Vendor Acquisition & Divestiture) Evaluate Selected Vendors Negotiate Contracts Onboard Vendors Manage Transitions Vendor Dispositions 25 Vendor Management Framework (Managing Vendors) Manage Contracts & Finances Manage Performance Manage Relationships
- 16. Align Demand & Capacity Management Manage Vendor Risk 26 Vendor Management Framework (Establish & Articulate Value) Manage Communications Plan Establish Vendor Operating Model Define & Manage Continuous Improvement Drive Innovation Develop Dashboards & Analytics 27 Vendor Governance Vendor Governance: vendor governance assigns the rights and responsibilities for all the decisions regarding the use and management of vendors, with the objective of managing the organization’s risks and achieving desired business outcomes. Vendor governance is a subset of corporate and IT governance frameworks. 28
- 17. Assignments Chapters 5, 6, 10 (IT Managers Handbook) Homework 6: Cloud & Vendor Management 29 Harrisburg University ISEM 547 Cloud Services Management Objectives Cloud Computing Overview Cloud Computing Characteristics Cloud Computing Models Cloud Computing Deployment Models Demarks of Ownership Cloud Computing Opportunities Cloud Computing Controls & Accountability Outsourcing Considerations with Cloud Computing 2
- 18. Cloud Computing Models Definitions, Structures, and Pros & Cons 3 What is Cloud Computing? Cloud computing, also on-demand computing, is a kind of Internet-based computing that provides shared processing
- 19. resources and data to computers and other devices on demand. The cloud computing model is composed of five essential characteristics, three service models, and four deployment models 4 Cloud Computing Models Characteristics The cloud computing model essential characteristics On-demand self-service Broad Network Access Resource Pooling Rapid Elasticity Measured Service 5 Cloud Computing Models Software as a Service (SaaS) Platform as a Service (PaaS) Infrastructure as a Service (IaaS) 6
- 20. Cloud Computing Deployment Models Private Cloud Community Cloud Public Cloud Hybrid 7 Cloud Computing Models - Ownership 8 Cloud Computing Models - Opportunities Staff Specialization Platform Strength Resource Availability Backup & Recovery Mobile Endpoints
- 21. Data Concentration 9 Cloud Computing Models - Accountability Loss of Control Service Agreements Security & Privacy Governance Compliance Laws & Regulations Data Location 10 Cloud Computing Models - Accountability Electronic Discovery Trust Data Ownership Composite Service Visibility Ancillary Data Risk Management 11
- 22. Cloud Computing Models - Accountability Architecture Virtual Machine Environments Virtual Network Protection Client Side Protection Identity & Access Management Data Protection & Availability Data Sanitization 12 Cloud Computing Models - Accountability Availability - Outages Incident Response Incident Analysis & Resolution 13 Cloud Computing Models – Preliminary Activities Preliminary Activities when considering the use of cloud services
- 23. Specify Requirements Exit Strategy Compliance Service Agreement Security & Privacy Risk Assessments Underlying Technology 14 Cloud Computing Models – Preliminary Activities Cloud Provider Viability & Competency Experience and technical expertise of personnel The vetting process personnel undergo Quality and frequency of security and privacy awareness training provided to personnel Account management practices and accountability The type and effectiveness of the security services provided and underlying mechanisms used The adoption rate of new technologies Change management procedures and processes The cloud provider’s track record The ability of the cloud provider to meet the organization’s security and privacy policy, procedures, and regulatory compliance needs Position and financial strength in the industry 15
- 24. Cloud Computing Models – Preliminary Activities Cloud Provider Contractual Obligations A detailed description of the service environment, including facility locations and applicable security requirements Policies, procedures, and standards, including vetting and management of staff Predefined service levels and associated costs The process for assessing the cloud provider’s compliance with the service level agreement, including independent audits and testing Specific remedies for harm caused or noncompliance by the cloud provider The period of performance and due dates for any deliverable The cloud provider’s points of interface with the organization The organization’s responsibilities for providing relevant information and resources to the cloud provider Procedures, protections, and restrictions for collocating or commingling organizational data and for handling sensitive data The cloud provider’s obligations upon contract termination, such as the return and expunging of organizational data 16 Cloud Computing Models – Preliminary Activities Additional areas where the terms of the service agreement should have extreme clarity to avoid potential problems. Ownership rights over data Locus of organizational data within the cloud environment Security and privacy performance visibility
- 25. Service availability and contingency options Data backup and recovery Incident response coordination and information sharing Disaster recovery. 17 Cloud Computing Models – Preliminary Activities An effective operational continuous monitoring program as one that includes: Configuration management and control processes for information systems; Security impact analyses on proposed or actual changes to information systems and environments of operation; Assessment of selected security controls (including system- specific, hybrid, and common controls) based on the defined continuous monitoring strategy; Security status reporting to appropriate officials; and Active involvement by authorizing officials in the ongoing management of information system-related security risks. 18 Readings & Assignments Chapters 5, 6, 8, 10 (IT Managers Handbook) 19