TPA, Self-Adjudication or Hybrid? What PACE Leaders Shared at NPA 2026

As PACE organizations grow, one of the biggest operational decisions leaders face is how to run claims administration. Should you partner with a third-party administrator (TPA), build the expertise to self-adjudicate, or do some of both?

At the National PACE Association Annual Conference in Denver, our session “TPA Decoded: Making Sense of Claims Administration for Leaders in PACE” put that question to two programs that answered it differently. Dr. Rebecca Schreiner and Jessica Lynch of Collabrios Health moderated a discussion with Mary Kiefert, Executive Director of Mount Sinai Eldercare, and Ashley Echols and Diana Yochum of Cherokee Elder Care. The goal was simple: give PACE organizations the floor to share their experiences of what worked and what didn’t.

Three ways to run PACE claims

TPA model: A specialized administrative partner manages critical operational functions, including claims processing, provider services, enrollment support, compliance, reporting and financial administration.
Self-adjudication model: The PACE organization manages all of those functions in-house.
Hybrid model: The PACE organization handles some functions itself and contracts with a TPA for others.

There’s no single right answer. The right model depends on a program’s size, growth plans, internal expertise and priorities, which is exactly what our panelists described.

Mount Sinai Eldercare: from multiple vendors to one accountable partner

For Mount Sinai Eldercare, the decision came at a turning point. Their existing TPA was leaving the PACE space, and the program didn’t have the internal expertise to bring claims in-house. As Mary Kiefert described it, the biggest decision became which TPA to choose.

Their priorities were real-time information and strong vendor relationships. They chose a partner they already worked with, one with deep PACE experience and a fully integrated EHR and TPA:

One vendor, one contact: A single account representative for both EHR and TPA questions, instead of coordinating across several vendors
Full-service operations: Medicare enrollment, RAPS and encounter reporting, and Medicaid AR and enrollment updates, with the partner retrieving 820 and 834 files on the program’s behalf
Network-wide visibility: Providers can check claim status and upload claims directly through a vendor portal

The result, in Mount Sinai’s experience: full integration traded the complexity of self-adjudication for consolidated visibility and support.

Cherokee Elder Care: from a cost-driven decision to a strategic operating model

Cherokee Elder Care took the opposite path. Their decision to self-adjudicate was initially driven by cost and control, and they’ve continued because it works. For Ashley Echols and Diana Yochum, the priorities were accessibility and control: knowing what’s happening immediately, building deep internal expertise and making a deliberate financial investment.

That model depends on people and process as much as technology:

A cross-trained team: Finance and compliance staff, including a payment coordinator, financial analyst and CFO, are cross-trained in claims, enrollment, accounts payable and provider agreements
Built-in oversight: The team monitors CMS guidance, holds biweekly operational and regulatory reviews and uses consulting support for analysis and benchmarking
Direct control: Electronic claims flow into the EHR, the internal team adjudicates and pays them, and direct data access supports timely research and corrections

In Cherokee’s experience, self-adjudication requires real investment in people, knowledge, systems and oversight, and in return it has provided greater control, visibility, responsiveness and continuity.

What both models have in common

Whichever model a program chooses, the panel kept returning to the same foundations:

Clinical documentation drives claims. In PACE, the IDT authorizes care, and a claim can only be paid when it matches an approved authorization. When clinical teams understand which service requests and statuses claims need, payment moves faster.
Compliance details matter. From fee schedules and DRG payments to sequestration, small details carry weight. For example, a plan can only recoup sequestration from a vendor if the vendor contract includes that language.
Timely payment is a requirement. CMS and some states can impose interest, penalties and fines when claims aren’t paid on time.
Continuity protects the program. Cross-training, documentation and succession planning keep operations steady through turnover and rapid growth, under any model.
Security is non-negotiable. Whether you build or buy, look for SOC 2 Type II and HITRUST certifications in the systems that handle participant data.

Questions every PACE leader should ask

The session closed with a framework for leaders weighing their options, whether they’re choosing a model for the first time or reconsidering the one they have:

What are your top priorities: cost, control, expertise or risk management?
How will your model scale as enrollment grows or you expand into new service areas?
What happens if key claims staff leave, and how is institutional knowledge preserved?
How well does your clinical information connect to your claims process?
What warning signs would tell you a model is no longer the right fit?

Five checkpoints every PACE claim must clear

Whatever model you choose, every outside bill moves through the same five checkpoints on its way to payment: intake, eligibility, pricing and contract, authorization, and delivery and payment. Our one-page checklist breaks down what each checkpoint confirms, what to watch for, and three questions to take back to your team.

See where your program stands

Thank you to Mary Kiefert, Ashley Echols and Diana Yochum for sharing their experience so openly, and to everyone who joined the conversation in Denver.

Download the five-checkpoint checklist to share with your team. Then schedule a claims consultation with Michelle Slade, Sales Solution Engineer at Collabrios Health, to talk through your current model and see where your program stands.