VIP Care Services

VIP Care Services is a Caprock Health Group affiliate focused on providing clinical and cost containment services. The clinical service division of VIP Care Services is VIP Care Management while the cost containment division is Medical Claim Review Services, The goal of VIP Care Services is to lower plan costs and improve member health. We believe those things go hand in hand. Our industry leading care management solutions and cost containment services empower employees and provide unsurpassed clinical tools to improve member health. The combined services provide proven, cost-effective methods for achieving hard dollar savings above and beyond the national averages. VIP Care Services is committed to offering a proactive approach to improving member health and reducing costs for long-term financial stability of the client health plans we serve.

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VIPCare Management

At Caprock HealthPlans our goal is to lower plan costs and improve member health. We believe those things go hand in hand. Our industry leading care management solutions and cost containment services empower employees and provide unsurpassed clinical tools to improve member health. Our VIP Care Management services provide proven, cost-effective methods for achieving hard dollar savings above and beyond the national averages. VIP Care offers a proactive approach to improving member health; reducing costs for long-term financial stability.

We offer multiple customizable options to meet the needs of any individual group.

Our services include:

  • » Predictive Population Management
  • » Disease Management
  • » Wellness Services
  • » Case Management
  • » Maternity Management
  • » Transplant Management
  • » 24/7 Nurse Line
  • » Diabetes Management
  • » Cost Containment Services

Predictive Population Management

Our innovative population health management solution provides accurate information in an integrated model to create client-specific care management plans targeted to each group's specific medical conditions. The program provides proactive risk stratification of high-risk patient populations as the first, important step to significantly improving the health of the patient community and reduces the cost burdens linked to chronic illness. This patient-centric population health improvement model integrates the predictive modeling, care coordination workflow tools and tracking analytics to engage and equip members with prevention and education tools, to promote compliance with care plans to address both illness and long -term health.

The use of predictive modeling through the analysis of members' monthly claims data and prescription data identifies tomorrow's high-risk members. VIP Care utilizes the health care industry's most sophisticated forecasting technology in the field of predictive analytics and clinical outcomes analysis.

MEDai products provide Caprock with the following:
  • » Identification and stratification of high-risk/high-cost members
  • » Accurate forecasting of future health plan costs
  • » Identification of cost drivers for high-risk populations
  • » Evaluation of patient patterns over time
  • » Actuarial and underwriting support
  • » Evidence-based medicine guideline compliance monitoring

By integrating state-of-the-art disease management and care coordination programs with the predictive modeling data, VIP Care is able to proactively support members with chronic medical conditions. Our patient centered support services and education tools are at the core of the program which is focused on improving member health and enhancing quality of life. The effective use of predictive modeling allows our clients to improve member health and lower plan costs on a consistent basis.

Disease Management

VIP Care disease management program is a comprehensive, integrated, multidisciplinary team approach to addressing a chronic illness in a proactive fashion, rather than waiting until an acute episode occurs. Our programs positively affect the patient through identification, early intervention, education, treatment plan compliance, and helping the patient achieve self-management and acceptance of responsibility for healthier life-style changes.

VIP Care applies a behavioral management approach to chronic condition disease management in order to assist the member to become ready for change. Participants move through Stages of Readiness for Change, beginning with Pre-contemplation (uninformed about their risk and need for change or not interested in changing), to Contemplation (considering change, becoming anxious about risks), to Preparation (readiness for action).

Our clinical staff is supported by evidenced based clinical practice guidelines, including Milliman Care Guidelines and guidelines through the National Institute of Health, American Heart Association, American Diabetes Association, and the American Lung Association. Nurses have access to a medical director who is board certified in Internal Medicine, along with content experts including pulmonology, endocrinology, and cardiology. VIP Care accesses a physician panel which comprises more than 200 board-certified physicians covering all clinical specialties.

Wellness Services

VIP Care believes that the best way to improve member health is a strong focus on wellness. Our integrated wellness programs provide our clients the tools, support, and information needed to proactively focus on areas of need in a positive, team-oriented environment.

The primary emphasis of this program includes the following conditions
  • » Obesity
  • » Metabolic Syndrome
  • » Pre-Diabetes
  • » Smoking Cessation
  • » Nutrition
  • » Exercise
  • » Cholesterol
  • » Blood Pressure Management

Our online health improvement system for wellness includes:

Lifestyle Assessment

Identifies common conditions, physical activity, preventive screening, pain, behaviors and barriers to health.


Tailored for each employee, the short action emails engage employees in learning and practicing new healthy skills. This also includes private email communications with a health coach.

Tracking Tools

Employees chart actions and record biometrics so they can watch their progress.

Employer Tools

Online aggregate data for employers; participation, demographics and results

Our wellness program assists employees in making behavior changes in areas that cost employees and employers significant sums of money in health care costs. We provide a preventive health program that relies on personal initiative and regular employer communications where every participant can benefit from working one-on-one with their health coach either on-line or telephonically. Employees have access to unlimited telephonic or inbound instant messaging access to a Certified Health Coach.

Health Risk Assessments (HRA)

An Health Risk Assessment (HRA) is the foundation of any successful wellness program. VIP Care provides a comprehensive, customizable, and scientifically based Health Risk Assessment as a valuable tool for our members. Our HRA gives members the ability to assess risk and target specific areas of need. By identifying members with new disease states or uncontrolled conditions, VIP Care can refer members into disease management or wellness programs tailored to their individual needs.

Case Management

VIP Care case management program actively manages the complex and costly care of the chronically or catastrophically ill patients. The case manager collects in-depth relevant information about a patient's situation to identify individual needs in order to create a comprehensive case management plan. VIP Care utilizes information from all relevant resources to ensure the patient is reaching desired outcomes and goals.

Maternity Management

Whether a normal or high-risk birth, our nurse specialists share their knowledge of prenatal care through education, communication and compassion. Our comprehensive maternity management provides careful monitoring and identifies at-risk situations where critical care would be appropriate.

Nurse specialists encourage mothers to pursue and live a healthy lifestyle. Mothers benefit from ongoing discussion and input. Should complications arise, monitoring and intervention are advocated.

As a comprehensive maternity/neonatal monitoring program, continuity in care begins at the onset of need and continues through post hospital discharge for the infant.

Utilization Review

VIP Care offers pre-admission, concurrent and retrospective review of both inpatient and outpatient medical services. The VIP Care advantage is our post-procedure contact to assist with after-care needs, ensure follow-up, and coordinate continued care. This follow-up frequently closes gaps in care in order to facilitate recovery and prevent relapse.

The utilization review process begins with one call to VIP Care management a toll-free number. Our goal is to simplify the system for the insured and all family members.

While doing this, we will:
  • » Answer all questions
  • » Channel to PPO providers and networks
  • » Anticipate discharge planning needs
  • » Prescreen for case management
  • » Submit shock loss reports according to your specifications

The insured, a family member, hospital representative or the doctor can pre-certify via Internet or by phone at 1-888-828-4901. If notified of the confinement by a provider, our contracted nurses will contact the insured and/or family.

VIP Care offers a variety of reports and delivery methods including direct-connect FTP services and anytime online reporting at no additional charge. Online, you can review pre-certification and case management status as often as needed. If data is collected, we can report it.

VIP Care utilizes a solid base of knowledge from a panel of over 200 highly qualified physicians to ensure appropriate opinions. Practicing physicians hold specialty board certifications in virtually every area of practice.

Transplant Management

Caprock HealthPlans Specialty Case Management partner program nurses provide the team of expertise required for success with each patient in their coordination of services before, during, and after the transplant. With extensive education of the overall transplant procedure, our specialty nurses will continue to manage the patient throughout the process providing continuity of care, education and support to the patient and family members.

Transplant program provides:

  • » Patient access to transplant Centers of Excellence Network
  • » Transplant Nurse Case Managers
  • » Member Clinical Advocates
  • » Top transplant physicians to optimize patient outcome
  • » Experienced transplant management with the patient’s well-being in mind at all times

Caprock HealthPlans understands the impact a transplant has on the patient and their plan therefore Caprock HealthPlans is fully committed to helping maximize both care and savings.

24/7 Nurse Line

Caprock HealthPlans 24/7 Nurse Line is an essential part of an employer's cost-containment strategy. The 24/7 Nurse Line provides affordable access to a nurse at any time of day. This access helps members avoid unnecessary and costly trips to the doctor or hospital ER by proving medical assistance from a licenses nurse.

The Nurse Line provides:
  • » Online health tools and resources
  • » 24/7 access to licensed nurses available in English, Spanish, and multiple other languages
  • » Client-specific reporting

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Medical Claim Review Services focuses on improving member health and lowering plan costs. In today's high cost environment it is essential for an employer group to utilize every conceivable mechanism to lower claims cost while consistently working to improve member health. Caprock HealthPlans provides cutting edge cost containment strategies designed to lower claims cost for our clients.

At the Caprock Health Group we focus on controlling claims cost on multiple levels, including:

  • » Dialysis Management
  • » Diabetes Management
  • » Specialty Cancer Care Services
  • » Management of high cost Rx
  • » Bill Review and Bill Audit services
  • » Negotiation of both pre and post service medical claims
  • » Negotiations for high cost out of network claims
  • » Secondary Network access to assure discount capture of smaller out of network claims
  • » Cost containment vendor management
  • » Employer specific provider contracting

Dialysis Management

In today's high cost world, the expense for dialysis has grown to historic levels. Many dialysis firms can charge up to 900% of Medicare reimbursement amounts for dialysis. Caprock HealthPlans employs multiple dialysis cost containment structures designed to reduce the plan costs for dialysis while providing access to quality care for the member.

To learn how we can help you reduce your dialysis cost and lower your plan expense, please Contact Us.

Diabetes Management

Approximately 8 - 10 percent of health plans' total covered population has diabetes, which accounts for approximately 36% of the total health care spend each year.

Caprock HealthPlans diabetes management program produces real-time evidence-based measures of patients' current disease status, which is used to improve both the length and quality of patients' lives. This real-time reporting allows Caprock HealthPlans to provide immediate blood glucose readings to patients, caregivers, physicians, and care managers.

More than 50 percent of Americans could have diabetes or pre-diabetes by 2020 at a cost of $3.35 trillion over the next decade if current trends continue.

Through a standard Internet browser patients, payers, physicians, and care managers may access health information and statistics

By converting used diabetes test strips from trash into data points, our clients are able to capture blood glucose information that has not previously been available. A variety of reports can be generated, which detail the clinical, biometric and financial performance of the group. For HIPAA purposes all information provided to the benefit plan will be aggregated de-identified data so that no Personal Health Information (PHI) is compromised or breached.

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