AEP 2025: The Compliance and Cost Risks of Manual Enrollment for TPAs

Every October, the healthcare industry braces for its busiest season: the Medicare Annual Enrollment Period (AEP). For payers and third-party administrators in Florida, this six‑week window can define the entire year’s success or risk millions in penalties and lost members.

Here’s why this pressure is so intense: Florida is a Medicare Advantage (MA) powerhouse. As of 2025, over 2.8 million Floridians are enrolled in MA plans, representing 57% of all eligible seniors.¹ That puts Florida well above the national average penetration rate of ~51%.

With Florida’s Medicare Advantage market size, these volumes magnify into systemic breakdowns. During AEP, this translates to:

• Enrollment requests numbering in the hundreds of thousands.
• Call centers face double their usual volumes.
• Back‑office staff get buried in paper forms and manual reconciliations.
• CMS audit scrutiny intensifies on MA leaders operating in the state.

The truth is simple: every year, AEP exposes cracks in legacy systems. The TPAs who come out ahead aren’t the ones “managing the chaos;” they’re the ones eliminating it through digital transformation.

Why Florida (and similar High‑Volume States) face the toughest AEP Challenges

Florida isn’t just another Medicare Advantage market. It is the proving ground for administrative resilience.

1. High Penetration = High Pressure

With more than half of all eligible Floridians in Medicare Advantage, TPAs must handle larger surges per capita than in most other states.

2. Complex Demographics

Eligibility checks in Florida are uniquely complex, with high volumes of dual‑eligible members and retirees who change residences seasonally, increasing the risk of mismatched records.

3. Hyper‑Competitive Market

Dozens of MA and Part D plans operate in Florida, which means switching activity, disputes, and member questions peak higher here than in smaller states.

4. CMS Oversight Magnified

Because Florida accounts for such a large slice of national MA enrollment, it’s also the top priority for federal audits and enforcement.

Florida is the ultimate proving ground. A TPA that can master AEP here can master it anywhere.

What are the real AEP Pain Points for TPAs

Beyond the surface-level challenges, these are the operational realities TPAs must address during AEP:

1. Paper Applications → Bottlenecks & Errors

Even in 2025, thousands of Florida beneficiaries still begin enrollment with paper forms. That leads to:

• Data entry mistakes (wrong SSNs, missing DOBs)
• Weeks‑long processing delays
• Incomplete records that trigger CMS/OIG audit flags

OIG 2023 Review found “unsupported or inaccurate enrollment records” remain the #1 recurring audit issue in Medicare Advantage.²

2. Call Centers Overloaded by Double Volumes

Call volumes spike by up to 100% during AEP. For TPAs:

• Average wait times stretch beyond an hour
• Inconsistent responses erode trust
• Member frustration often escalates into formal CMS complaints, directly impacting Star Ratings

The consequence of declining Star Ratings is severe: MA plans face millions in forfeited bonus payments, alongside a significant reputational blow that directly impacts their third-party administrators.

3. Compliance Audits & Penalties

CMS enrollment rules are unforgiving. TPAs must:

• Validate eligibility within 7–10 days
• Maintain proof of every approval and denial
• Document appeals and disputes

In 2025, CMS issued multiple six‑figure penalties tied to MA and Part D enrollment mismanagement.³

For third-party administrators in Florida, where volumes magnify risk, one overlooked process step can equal a $250,000+ fine.

4. Member Experience Breakdowns

When admin errors happen, members feel them immediately:

• Delayed ID cards lead to denied prescriptions
• Billing mismatches wrongly charge seniors
• Eligibility errors cause rejected claims at the provider’s office

These issues don’t just frustrate; they result in grievances and switching behavior, cutting retention.

5. Fragmented Legacy Systems

Enrollment, billing, claims, and eligibility often run on disconnected platforms. The result:

• Manual file uploads and duplicate entries
• Delayed reconciliations
• Blind spots for executives until problems have already escalated

Every AEP becomes a cycle of manual fixes and reactive workarounds rather than proactive management.

For TPAs looking to modernize beyond paper-heavy, fragmented processes, platforms like Mirra’s Medicare Advantage-in-a-Box provide an integrated approach to eligibility, enrollment, and member management.

Also read: AEP Claims Success: Accuracy, Denial Prevention & Trust

How Does Manual AEP Compare to a Digital-First Approach? 

Here’s why digital TPAs consistently outperform manual operators:

How Mirra Health Care delivers end-to-End AEP Transformation as a Leading Third-Party Administrator in Florida 

Mirra Health Care isn’t just a technology add‑on. It operates as a tech-first TPA, providing Medicare Advantage plans with end‑to‑end administrative services across eligibility, enrollment, and member management.

• Digital Enrollment Processing - Replace paper forms and manual entry with CMS‑ready digital workflows.
• Centralized Eligibility & Member Management - One integrated platform unifies enrollment, billing, and claims, preventing mismatches.
• Compliance by Design - Every workflow is structured to remain audit‑ready, with complete record traceability.
• Automation + Member Portals - Self‑service enrollment, plan comparison, and FAQs reduce call center load while improving member satisfaction.
• Operational Dashboards - Gain real‑time visibility into enrollment volumes, exceptions, and compliance risks, enabling faster action before issues escalate.

With Mirra, third-party administrators in Florida shift AEP from fragmented, reactive operations to a unified, compliance‑driven model that scales with demand.

The Future of Enrollment: Why Digital-First is no longer Optional 

The U.S. healthcare landscape has shifted. It’s no longer a matter of if TPAs must digitize; the only question left is how fast.

• By 2025, more than 70% of payers and TPAs will have increased spending on digital enrollment and eligibility platforms .
• In Florida, Medicare Advantage enrollment continues to grow 8–9% year-over-year, compounding operational pressure.¹
• Meanwhile, CMS enforcement actions and civil monetary penalties have accelerated, with fines now routinely crossing six figures.

Looking ahead, TPAs will need to adopt:

• AI‑Assisted Intake → detecting incomplete or risky applications before CMS submission.
• Predictive Analytics → forecasting call spikes, switching behavior, and processing backlogs.
• End‑to‑End Integrations → connecting payers, providers, members, and TPAs into a seamless ecosystem for real‑time eligibility and claims validation.

The Takeaway: falling behind on digital isn’t just a technical lag; it’s lost revenue, lower Star Ratings, and compliance risk.

That’s why TPAs in high-demand states are investing in digital-first platforms like Mirra Health Care. To stay audit-ready and member-focused during AEP.

Read on our blog post on Cut Costs, Ensure Compliance with Enrollment Management Software

For more strategic perspectives and industry updates on enrollment, compliance, and member management, explore Mirra Health Care Insights

Conclusion

The complexity of AEP will only increase: more members, stricter oversight, and rising expectations for service quality. What TPAs need is not incremental fixes, but an operational model that ensures accuracy, scalability, and compliance at every step.

The industry trend is already clear: technology‑driven TPAs are better positioned to withstand scrutiny and protect Star Ratings. Those that remain reliant on paper processes and fragmented systems will continue to face fines, member grievances, and reputational risk.

Mirra Health Care illustrates how a tech‑first approach can change the AEP equation. By digitizing enrollment, unifying eligibility and claims, embedding compliance, and enabling proactive oversight, Mirra demonstrates what the next generation of TPA operations can look like.

The real question for TPAs isn’t whether AEP gets harder - it does. It’s whether you choose to stay reactive or invest in becoming digital‑first and compliance‑ready from day one.

Learn more about how Mirra Health Care helps TPAs cut paper-driven errors, reduce call spikes by up to 40% with automation, and stay audit-ready with CMS-compliant digital workflows.