PCP searches in Find Care
The personalized match algorithms used to sort specialty searches use a combination of member and provider features to sort and display the results for a member’s search. The sorting results take into account member factors, such as the member’s medical conditions and demographics. Personalized match models for each provider specialty type were created, including one specifically for PCP provider specialists.
Quality and compliance for provider searches are based on over 100 quality of care rules that monitor member prevention, medication, diagnostic testing, and various additional aspects of care based on HEDIS® and other metrics that are proven indicators of the pursuit of high-quality care. Quality rules are updated periodically as standard of care guidelines evolve.
Combined member and provider features generate a unique ranking of specialists for each member conducting a provider search. Displayed first are provider specialties with the highest overall ranking within the search radius. Remaining specialists are displayed in descending order, based on overall rank and proximity to the center of the search radius.
On or after January 13, 2023, we will further refine our PCP specialty model results with additional business logic associated with the individual PCP’s associated provider group’s cost efficiency and quality of care.
- Cost efficiency for the provider group takes into account not only the member’s PCP‑related costs but all care costs associated with the member. These costs are risk adjusted.
- A provider group’s cost efficiency and quality metrics are combined to establish the list of provider groups that satisfy the provider group applied metric (PGAM).
- The PGAM cost and quality metrics will be compared to statewide benchmarks and scored as indexes with a value of >=1 designated as at or above the benchmark.
- Cost and quality indexes will be added to create a provider group performance score.
- Provider groups with either a performance score in the top 25th percentile or who have earned both cost and quality indexes >=1 will be designated as having met the PGAM metric.
In-network individual providers who are associated with provider groups that meet the PGAM metric will appear at the top of the search result, listing above those individual providers who do not qualify for being assigned a PGAM score. Those individual providers assigned to provider groups that did not meet the PGAM metric will appear below those provider groups that are not included for the PGAM assignment. Within the levels informed by the PGAM, individual providers will be sub sorted by a personalized match PCP model score, with tie scores further sub sorted by proximity and last name.
You may review a copy of the updated methodology by going to Availity > Payer Spaces > Anthem > Information Center > Administrative Support > Personalized Match Search Methodology_CSBD.
If you have general questions about the Find Care tool, the change to the quality measures for procedure searches, or if you would like to request reconsideration of those factors, you may do so by emailing firstname.lastname@example.org.
PCP searches in Find Care - Wisconsin