TPAs and CMS Audits: Is Your Readiness Protecting Clients—or Creating Risk?

By Laura Massetti, Chief Growth and Marketing Officer

3 min read

TPAs sit at the center of Medicare operations, managing critical functions for multiple health plans and keeping complex programs running behind the scenes. Most days, that work is invisible—until a CMS audit arrives.

That's when the question shifts from "Are things running?" to "Can we prove they ran correctly?"

And increasingly, that burden falls squarely on TPAs.

Health plans hold the CMS contract, but audits don't stop at organizational boundaries. When member communications, enrollment processes, billing, or data handling involve a vendor, CMS expects the same level of control, documentation, and defensibility as if the plan managed it internally.

No exceptions.

The Gap That Emerges Under Pressure

In theory, everyone knows their role. In practice, audits expose gaps invisible in daily operations.

The moment of truth comes when a plan must produce evidence quickly—not summaries or explanations, but actual proof:

• When was the notice generated?

• Which version was sent?

• How do you confirm this member received it?

• What happened when mail was returned?

These aren't trick questions. They're standard audit inquiries. Yet many TPAs struggle to answer them clearly, especially across multiple clients, vendors, and customized workflows.

Risk doesn't come from work left undone—it comes from work that can't be demonstrated under scrutiny.

CMS auditors aren't looking for perfection. They're looking for control.

They want evidence that required communications were sent on time, using approved content, to the right members. They need to understand data flow: who touches it, how errors are caught, and what happens when problems arise—bad addresses, returned mail, missed deliveries.

Above all, they want documentation. Logs. Files. Records that prove processes exist beyond institutional knowledge and email threads.

When a TPA can't produce this information quickly, the plan owns the finding. But the pressure flows downstream—and relationships suffer.

Here's the uncomfortable reality: doing the work well is no longer sufficient.

In today's audit environment, strong partners demonstrate their value by standing confidently beside clients when auditors come calling. That requires:

• Repeatable, documented processes

• Consistent evidence trails

• Clear answers to detailed questions

• Defined responsibilities established before audits begin

When audit roles aren't clarified upfront, everyone scrambles—and that's when mistakes happen.

The TPAs differentiating themselves aren't just operationally capable—they're audit-ready by design.

They've invested in visibility, not just throughput. They've standardized processes across clients while respecting plan-specific requirements. They recognize that communication workflows, return mail handling, and data integrity are compliance functions, not administrative tasks.

Health plans notice. In an increasingly regulated environment, trust is built on proof.

CMS audits aren't new, but expectations are evolving. The question for TPAs isn't whether you support audited functions—you already do.

The real question: When an audit happens, are you positioned as the partner who protects your clients, or a gap they have to explain?

At Command Direct, we partner with health plans, TPAs, and MSOs who recognize that modern compliance extends beyond checkboxes. It's about building operations that withstand scrutiny—calmly, clearly, and confidently.