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As part of our continuing effort to partner with and promote transparency in sharing information with Alabama participating network physicians, Blue Cross and Blue Shield of Alabama publishes Preferred Medical Doctor (PMD) Profiles quarterly. The profile includes overall cost and utilization measures for a particular physician as compared to statistically adjusted measures for that physician’s PMD peer group. This profile should be a mirror image of the physician’s practice patterns and should not come as a surprise to the PMD physician. The profile is intended for educational purposes and serves as a reference point for communication between the provider and Blue Cross. The profile data is retrieved from claims received; therefore, it is as accurate as our claims data.
Physician EDI Profiles
Blue Cross and Blue Shield of Alabama publishes a physician Electronic Data Interchange (EDI) Profiles. The EDI Profile is a presentation of the physician’s EDI activity over a quarter year’s time. It displays the identifying information used to run the report, claim counts and the corresponding EDI to paper claim percentage. A comparison of the physician’s electronic claims percent to the peer group is included. The peer group is derived from all providers with the same specialty as noted in the identifying information. Page two of the profile explains the sections of the report and includes a detailed description of each field on the profile page. In addition to claim activity, the profile includes other transaction activities such as eligibility and benefits, claim status, referrals and precertifications. The most common claim submission errors received in the physician’s audit reports are also listed.
Surgical Episodes Reports
Blue Cross and Blue Shield of Alabama developed a data profiling system that compares episode costs, length of stay, ancillary costs and patient morbidity index for surgical procedures. Surgical Episodes Reports are updated quarterly and are available if there is episode data for the physician.
Accessing Profiles and Surgical Episodes Reports
Below are instructions on how to access your Profiles and Surgical Episodes Reports:
Last Updated March 2010