SOC 2 attestation isn’t just a strategic move for executives. It’s a practical project that lands squarely on the desks of behavioral health program managers and IT leaders. The audit itself may be conducted by CPAs, but the preparation? That’s your job. And while it can feel daunting at first, with the right approach and the right tools, it’s absolutely within reach.
SOC 2 is a voluntary but widely respected framework for managing data security and privacy. Developed by the American Institute of Certified Public Accountants, it’s built around five Trust Services Criteria: Security, Availability, Confidentiality, Processing Integrity, and Privacy.
Most behavioral health organizations include Security by default and often add Availability and Confidentiality. Privacy may be added when services go beyond standard care, such as community outreach or research. Processing Integrity comes into play when you’re managing complex billing systems or data feeds for reporting.
There are two types of SOC 2 reports. Type 1 checks whether your controls are properly designed at a single point in time. Type 2, which is more widely valued, assesses whether those controls actually work over a period of several months. For behavioral health providers looking to demonstrate reliability to payers, partners, and patients, Type 2 is the target.
Phase One: Defining What’s in Scope
Before anything else, you need to define the boundaries of your SOC 2 project. Are you auditing the entire organization or just a subset, like a telehealth platform or data warehouse? What systems, services, and locations are involved?
You’ll also need to identify which Trust Services Criteria apply. That decision should be based on the services you offer and the expectations of your clients, partners, and payers. Once that’s defined, it’s time for a readiness assessment.
This is a structured gap analysis comparing your current controls, policies, and procedures to what SOC 2 requires. It’s not about perfection. It’s about knowing where the gaps are so you can build a plan to close them. Many behavioral health teams bring in a partner like Xpio Health to help lead this assessment and keep the process on track.
Phase Two: Closing the Gaps
With the gaps identified, the real work begins. Controls need to be implemented, policies formalized, and documentation created. Common areas of focus include access control, data backup and recovery, incident response, change management, and vendor oversight.
This is where SOC 2 often feels like a documentation project as much as a technical one. Having strong practices in place is essential, but unless those practices are written down and followed consistently, they don’t count. Training plays a key role here too. Staff need to understand their responsibilities, especially when it comes to security awareness and reporting incidents.
As your policies take shape, the technical side needs to follow suit. You’ll need to align your systems with the controls you’re documenting. That often includes things like multi-factor authentication, encryption of data, log monitoring, and evidence of regular system updates and backups.
Phase Three: Proving It Works
A Type 2 audit is not about what you say you do. It’s about what you can prove you actually did. Over the course of six to twelve months, you’ll need to gather evidence that your controls were operating as intended.
This includes things like screenshots of system settings, audit logs, training records, incident response documentation, and more. The volume of evidence can be overwhelming if you’re relying on spreadsheets and file shares.
That’s where compliance automation tools come in. Platforms like Vanta (which Xpio Health supports) can connect to your cloud infrastructure, HR tools, and identity systems to automatically gather evidence, flag issues, and help maintain your compliance posture throughout the year. These tools don’t just prepare you for the audit. They help keep your operations secure in real time.
Phase Four: The Audit
Once the audit period ends and your evidence is in order, the CPA firm you’ve selected will begin their review. They’ll look at your documentation, test a sample of your controls, and interview key staff.
The audit is not adversarial. It’s a review of your work, not a pop quiz. If your team has been actively managing controls and documenting them along the way, the audit should be a structured wrap-up, not a fire drill.
After the Audit: Keeping It Going
SOC 2 isn’t a one-and-done milestone. It’s a continuous cycle. You’ll need to update controls as your systems change, conduct regular internal reviews, and keep staff training up to date.
The best organizations treat SOC 2 not as a project, but as part of their operating model. They build muscle memory around policies and processes so that audits become checkpoints, not crises.
A Note on HIPAA
If your organization already has HIPAA compliance in place, you’re not starting from zero. Access controls, encryption, vendor agreements, and security training all lay a strong foundation for SOC 2.
Where SOC 2 goes further is in scope, structure, and evidence. It covers more than PHI and demands proof of sustained operational effectiveness. Think of HIPAA as the floor and SOC 2 as a framework for building a stronger, more visible structure on top of it.
The Bottom Line
SOC 2 may be driven by executives, but it’s built by the people managing systems, leading teams, and keeping operations running every day. Behavioral health program and IT managers are the ones who make it real.
Yes, there’s work involved. But with the right plan, the right tools, and a focus on what really matters, SOC 2 can become a powerful part of your organization’s story, and not just another audit to survive.
What would it take to make SOC 2 manageable for your team? Reach out to Xpio Health and let’s build a practical roadmap together.
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