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The Prometheus Payment Engine

HCI3 contracted with MedAssets to develop an engine for PROMETHEUS Payment. In order to implement PROMETHEUS Payment, a pilot site must plug into or hook up to the PROMETHEUS engine. The engine is hosted by a service bureau to allow for easy "plug and play". The engine is a combination of a claims tracking and financial accounting system, along with a scorecard that uses both claims and other data, including medical records data, to measure the quality of care that is being delivered to patients.

The engine is a clinically based, financial "credit/debit" system that reconciles the actual cost of care against the predicted cost of care for any given ECR using existing claims data. The engine automatically calculates patient-specific ECRs, while also including a PAC allowance, the margin and the underuse adjustment. Upon the conclusion of an ECR, the engine will automatically and retrospectively tally actual accumulated costs versus predicted costs for Scorecard analysis. It follows these steps:

  • For each ECR, the Engine will use a "filter" to determine whether a claim is part of the ECR or not.
  • The "Navigator" will steer the claims to the appropriate decision categories, such as Exclude, Conclude, Terminate, PAC, or Typical.
  • The "Accumulator" reviews codes present on a claim and assigns the claim from the Typical bucket to any of the risk factor categories and adjusts the ECR.
  • For each ECR, the Prometheus engine has two accumulators, which function as the credit/debit account process. They hold the Typical and PAC claims in separate buckets and calculate the dollars associated with each bucket to perform the reconciliation process for the Scorecard analysis.

 

Each ECR will produce an output report. Every provider that manages or co-manages the patient (as evidenced by a claim) is associated with the ECR and will be listed in the report. Within the output reports, claims are split between typical and PAC buckets; and prospective budgets can be adjusted based on new data about the patient. The true-up by provider will look across all ECRs and will determine the net actual vs. budget. As a result, standard reports will be available for each pilot site. Additional reports can be created or tailored to meet the needs of the pilot site which can be used for further decision making. For these types of adhoc reports, an additional fee may apply. The standard reports are available to pilot sites and sent on a quarterly basis.