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American TPA Solutions for MLTC & PACE Programs (ATC) set a new services (BPO /TPA) standard for PACE & MLTC Clients servicing elderly, special needs and dual-eligible (Medicare-Medicaid) populations. Our Services to MLTC & PACE Clients include but not limited to

  1. Enrollment Services
  2. Eligibility Services
  3. Co-ordination of Benefits
  4. Service Authorization
  5. Customer Care including Russian & Spanish Language Support
  6. Claims Administration and Adjudication
  7. Grievances & Appeal
  8. Encounter Data Submission
  9. Compliance
  10. Reporting & Analytics

What is MLTC & PACE?

MLTC (Managed Long Term Care) Plan - MLTC plans provide long-term care services for Medicaid eligible persons age 18 and older. Services include home health care, nursing and personal care. Additionally, the MLTC plans provide medically necessary services that include dental care as well as medical equipment (DME). MLTC was created to serve as an alternative to the current system of costly, inefficient and undesirable institution-based care. It decreases financial burden for all stakeholders – health plans, hospitals, governments, and members – by preventing or reducing costly health events that occur far too frequently in aging populations, while simultaneous helping to reduce the emotional toll of aging.

PACE (Program for All Inclusive Care for the Elderly) - PACE provides a comprehensive health care plan for persons age 55 and older who are Medicaid and/or Medicare eligible and eligible for nursing home admission. Both Medicaid and Medicare pay for PACE services. PACE members are required to use PACE doctors. PACE is responsible for arranging all primary, in-patient hospital and long-term care services that are required by their members. In order to be eligible, consumers must require nursing home level of care.

ATC All Inclusive Low PMPM Solutions for PACE and MLTC

AMERICAN TPA is focused on providing maximum cost saving & customer service for MLTC & PACE Clients through leading edge technologies and best practices. We have compiled an infrastructure of systems that are on the forefront of managed long term care practices that allow us to remain paperless, secure and highly effective when processing healthcare transactions from authorizations to claims payment.
AMERICAN TPA provides integrated technology services designed to address the entire managed care life cycle i.e. from member enrollment, eligibility, credentialing, claims admin to care management. A closely coupled modules and workflows, integrate with third party applications (Plexis Claims and Cogniy Care Management Platform) gives AMERICAN TPA an efficient, effective and turn-key plug & play solution to administering the business of MLTC & PACE Healthcare.

AMERICAN TPA BPO / TPA Services for MLTC and PACE Clients

  • Enrollment, Eligibility & Credentialing - Besides Enrollment & Eligibility, our first touch of solution point is the credentialing process. AMERICAN TPA rigorous standards screen potential issues one may have with a provider before they can occur by excluding them from the network.
  • Claims Administration  - Claims payment is a costly and huge burden on MLTC / PACE Programs. AMERICAN TPA can centralize the submission and processing of those home care claims. One of the strengths of AMERICAN TPA is the ability to receive and process claims in a variety of formats. While traditional healthcare providers submit claims via HIPPA compliant electronic transactions or on a CMS 1500, non-health care providers use a variety of applications and formats. In addition, providers who are working directly for members through self-directed care will submit time sheets directly to the MLTC program.
  • Customer Care – Member and Provider Services. AMERICAN TPA takes pride in providing 24X7 or Follow-the-Sun Call Center / Customer Care support to MLTC / PACE Clients as per the need. We also have capabilities to provide Language Support in Russian, Spanish, Hindi, Urdu, Bengali and English.
  • Referrals and Authorizations (UM) - Using the most advanced technology in the marketplace, AMERICAN TPA can monitor in real-time the service being provided and verify those services against what has been authorized within the care plan. To ensure that needed services are delivered, a sophisticated process of referrals and authorizations is established; the authorized services are tracked and matched to individual claims for processing. By covering these components within our services, AMERICAN TPA directly impact client’s Quality Improvement initiatives as and compliance measures.
  • Advanced Analytics & Reporting - AMERICAN TPA Advanced Analytics is focused on providing a holistic evaluation of the member’s needs, including unparalleled access to a full suite of reporting capabilities to help evaluate the care provided to members and associated outcomes. A quick listing of our MLTC / PACE focused Analytics (including Predictive Analytics) are:
  1. Health Economics - Health economics analysis of your patient mix to set a realistic and predictable capitation cost for patient population. Capitation will improve cost structures, cash flows and P&L
  2. Quality Measures & benchmarking
  3. Claims (Fraud, Waste and Abuse) Analytics
    • Predictive fraud model/ fraud intelligence framework
  4. Population segmentation / clustering
  5. P&L by member – MLTC / PACE participant
  6. Forecasting of cash flows
  7. Reporting Metrics i.e. 
      • Profit decile
      • Cost per member
      • Top 5 member segments
      • By total cost
      • Bottom 10% of segments
      • By cost category (day care, specialist, physiotherapy, external)
      • Gross margin per member
      • Profit margin per segment
      • Cost vs. RAPS score
  • Claims & Care Management Software – AMERICAN TPA solution to PACE and MLTC client includes Claims and Care Management Software too. Our All Inclusive low PMPM pricing covers all i.e. Software, Consulting, Hosting and BPO / TPA Services.
  • Platform Partners – AMERICAN TPA works with leading edge technology partner to deliver best in class solution for PACE & MLTC clients.

To learn more our MLTC and PACE Software and BPO / TPA Services, Contact @ 201.258.4704 or. Source -  www.AMERICAN

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425 Washington Blvd.,
Jersey City,
New Jersey 07302,

Phone: +1 551.227.1525 | +1 201.258.4704
Fax : +1 201.604.3480
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