More Than a TPA: A Day-One Reflection From the NPA Conference
by Dr. Prince Baawuah, Head of Medicare Advantage Solutions
Halfway through our first full day on the exhibit floor at the National PACE Association Annual Conference, an attendee picked up a Falcon Health pen and wrote across the one-pager she had just taken from our booth:
"This company is more than a TPA."
She was answering the question I had heard all day. It is the moment I keep coming back to, because she was not repeating a tagline. She had decided for herself what Falcon was for.
"So you are a TPA?"
This was Falcon Health's first-ever exhibit, and for much of the PACE community, Falcon was a new name. The work was not new to me.
From 2014 to 2022 at CMS, I supported PACE organizations and Medicare Advantage plans through encounter data and risk adjustment operations: payment reconciliation, user group calls, CSSC Operations resources, and a steady stream of questions about what CMS accepted, what CMS paid, and what an organization still needed to fix. The questions came from finance directors, coders, and operations leads. They were not asking out of curiosity. They were trying to protect the programs that care for their participants.
That is what I heard again this week. When people stopped by the booth, heard "payment reconciliation, risk adjustment, encounter data, CMS files," and asked whether we were a TPA, I understood why. PACE organizations already work with administrators, payers, states, EHRs, claims processes, and finance workflows. When a new company says it can help reconcile payment and connect files, "TPA" is the natural category to reach for.
My answer, over and over, was:
"We are more than a TPA."
That is not a knock on TPAs. They do important work, and many PACE organizations rely on them. Falcon is built for a wider problem than administration alone.
What People Mean When They Ask "TPA"
At the booth, I heard the question as practical shorthand: Will you take work off our plate, process our files, and save us from manual reconciliation?
Yes, Falcon helps with those problems. But processing a file is not the same as understanding it. Falcon is designed to connect the data, explain the differences, surface the risk, preserve the evidence, and guide the next action, so the people doing the work can see what is actually happening.
On Monday, my colleague and Falcon Health's CTO, Yubin Park, looked at the NPA agenda and named the pattern we were both seeing in four verbs: connect the data, detect exceptions, guide action, and preserve evidence. After a full day of conversations, that framework had faces attached to it: a compliance lead preparing for an audit, a finance director trying to close the month, a risk adjustment manager tracking changes across several health plans.
Connect the data. Detect exceptions. Guide action. Preserve evidence.
That was the pattern in the agenda, and it was the pattern in the booth conversations.
PACE Payment Is a Chain, Not a File
PACE payment is not one payment and not one workflow.
Picture a single participant: an older adult who comes to the day center three times a week, recently had a fall, and just had a change in Medicaid eligibility. That one person can have Medicare capitation, Medicaid payment, frailty, Part D, enrollment changes, diagnosis documentation, encounter submission timing, and retrospective adjustments, all moving on different calendars.
Meanwhile, finance is looking at a CMS file. Someone else is looking at a state remittance. Another team is working from the internal enrollment record. A fourth is trying to confirm whether the diagnosis from that fall was documented, submitted, accepted, and reflected in a future risk score. Each team holds one piece of her story, and no one holds all of it.
A spreadsheet can hold the number. It cannot easily hold the explanation.
The explanation is the work.
When a participant's payment changes, the organization needs to know:
- Which participant changed, and which source showed it?
- Was the change expected, and was it paid correctly?
- Is there money to recover, or an overpayment to return?
- What evidence supports the answer?
- Who owns the next action, and can we explain it again later?
A TPA can administer part of that chain. Falcon is built to connect the whole chain and keep it tied to the person at the end of it.
Where Falcon Fits
The clearest way to place Falcon is by role, not by company:
| Primary job | Where the gap usually is | Falcon Health | |
|---|---|---|---|
| Claims or payment administration TPA | Process transactions, eligibility, and delegated administrative work | Shows that a transaction happened without explaining the full payment chain behind it | Reconciles payment participant by participant across Medicare, Medicaid, frailty, Part D, enrollment, and audit evidence |
| Encounter and risk adjustment operations | Submissions, CMS response tracking, risk score workflows | Stays in the risk adjustment lane, separate from finance and care operations | Ties diagnosis evidence and encounter status to the dollar impact and the participant's record |
| Analytics or reporting vendor | Dashboards, trends, management reports | Shows the variance without the record needed to resolve it | Takes you from a dashboard finding to the participant, the evidence, the dollar impact, and the next step |
The conversations on day one were not just about outsourcing a process. They were about understanding a complicated system well enough to serve people better through it.
The Difference Is Shared Explanation
Most PACE teams already have talented, committed people doing this work. Many of them got into PACE because they believe in keeping older adults at home and in their communities. What they often lack is one shared place where the work explains itself.
Finance understands the variance. Risk adjustment understands the diagnosis logic. Compliance understands the audit concern. Operations knows the file timing. A clinical leader knows whether the evidence is real, because they know the participant. Too often, each answer lives in a different system, spreadsheet, email thread, or someone's memory.
Falcon brings those views together without flattening the complexity. PACE payment is not simple, and we are not pretending it is. Our goal is to make it understandable, traceable, and actionable, with the person kept at the center of it.
A participant is not a row on a report.
Each one has an enrollment story, a payment story, a clinical story, and a submission story. When PACE staff can see those stories together, they stop working tickets and start working on behalf of a person.
Not Transactions. Transformations.
The TPA question told me something useful. PACE leaders are not looking for another abstract AI promise. They are trying to place Falcon on the real map of their organizations, and they asked us the questions that matter:
- Will this help us close faster?
- Will this help us understand what CMS and the state actually paid?
- Will this help us find missing dollars and return overpayments correctly?
- Will this help us explain risk adjustment changes?
- Will finance, compliance, operations, and risk adjustment finally see the same answer?
Those are the right questions. Each one is about more than money. A dollar recovered is a dollar back in the care model. An answer everyone shares is time returned to staff who would rather be serving participants than reconciling spreadsheets.
PACE does not need another disconnected dashboard, another black-box AI tool, or another spreadsheet that only one person understands. It needs shared understanding, and that starts with payment integrity. From there, the same participant's story can carry the questions that follow: population health through Helm, provider networks through Pulse, and claims and fraud, waste, and abuse through Sentinel.
So that is the answer I will keep giving. Falcon Health can do some of what people expect from a TPA, but our purpose is bigger: helping PACE organizations understand and act, participant by participant and exception by exception, without losing the participant's story or the evidence behind it.
A TPA is built for transactions. PACE was built for transformation.
Keeping older adults living safely in their homes and communities, with the care they need, is the point. Every file, every payment, and every diagnosis traces back to one of those people. When staff can see the participant's story, not just the transaction, the work itself changes.
Every file. Every participant. Every dollar. Reconciled.
Stay tuned for more reflections from the NPA conference.